This questionnaire will help you and your healthcare professional measure the impact COPD (Chronic Obstructive Pulmonary Disease) is having on your wellbeing and daily life. Your answers, and test score, can be used by you and your healthcare professional to help improve the management of your COPD and get the greatest benefit from treatment.
For each item below, please choose the box that best describes your health currently. Be sure to only select one response for each question.
Example: I am very happy 0 1 2 3 4 5 I am very sad.
A score of 1 would show that you feel far closer to the “I am very happy” statement.
I never cough
I cough all the time
I have no phlegm (mucus) in my chest at all
My chest is completely full of phlegm (mucus)
My chest does not feel tight at all
My chest feels very tight
When I walk up a hill or one flight of stairs I am not breathless
When I walk up a hill or one flight of stairs I am very breathless
I am not limited doing any activities at home
I am very limited doing activities at home
I am confident leaving my home despite my lung condition
I am not at all confident leaving my home because of my lung condition
I sleep soundly
I don’t sleep soundly because of my lung condition
I have lots of energy
I have no energy at all
TOTAL SCORE: 0
Thank-you for completing the test. Please submit your answers.