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, place a mark (X) in the box that best describes you currently. Be sure to only select one response for each question.
Know your score. Share your results with your doctor.
Step 1 Select the number of each answer in the score box provided.
Step 2 Add the score boxes to your total.
Step 3 Take the test to the doctor to talk about your score.
0 = I never cough.
5 = I cough all the time.
0 = I have no phlegm (mucus) in my chest at all.
5 = My chest is completely full of phlegm (mucus).
0 = My chest does not feel tight at all.
5 = My chest feels very tight.
0 = When I walk up a hill or one flight of stairs I am not breathless.
5 = When I walk up a hill or one flight of stairs I am breathless.
0 = I am not limited doing any activities at home.
5 = I am very limited doing activities at home.
0 = I am confident leaving my home despite my lung condition.
5 = I am not confident leaving my home because of my lung condition.
0 = I sleep soundly.
5 = I don't sleep soundly because of my lung condition.
0 = I have lots of energy.
5 = I have no energy at all.
Please leave this blank