PATIENT SELF ASSESSMENT
⚠️ TAKE YOUR TIME & CATCH YOUR BREATH IF NEEDED ⚠️
📋 PATIENT COPD ASSESSMENT & BACKGROUND
Full Name
Age
Primary Phone Number
Country
United States
United Kingdom
Other / International
State / Region / County
Select State / Region
🤝 Lifestyle & Daily Context
How long have you been dealing with breathing or lung challenges?
Less than 1 year
1 to 3 years
3 to 5 years
5 to 10 years
Over 10 years
What daily activity do you miss doing the most because of shortness of breath?
Walking in the neighborhood / gardening
Playing with grandkids / family outings
Doing house chores without stopping
Sleeping through the night comfortably
Traveling or social gatherings
How much is shortness of breath affecting your daily peace of mind?
Extremely frustrating & exhausting
Moderate daily annoyance
Manageable with frequent breaks
Causing high anxiety / worry
Have you tried natural or herbal remedies before?
No, this is my first time exploring natural care
Yes, used teas or home remedies with little relief
Yes, open to trying structured herbal support
Formal Diagnoses (Check all that apply)
COPD
Emphysema
Chronic Bronchitis
Asthma Overlap
Bronchiectasis
Resting SpO2 % Reading
Oxygen Tank / Concentrator Usage
Not using oxygen
Portable Concentrator (24/7)
Home Tank Only (Exertion/Night)
Continuous Flow
Oxygen Flow Rate (Liters per minute)
Breathlessness Level (mMRC Grade)
Level 1 - Only with heavy exercise
Level 2 - Short of breath walking up slight hills
Level 3 - Stops for breath on flat ground / walks slow
Level 4 - Stops for breath after 100 yards walking
Level 5 - Too breathless to leave house or get dressed
Daily Symptoms & Clinical Indicators
Heavy Daily Phlegm / Mucus
Symptoms Worst in Morning
Persistent Wheezing
Severe Chronic Fatigue
Sleep Disruption / Orthopnea
Smoking History & Environmental Triggers
Current Smoker
Former Smoker
Never Smoked
Chemical / Dust Exposure
Current Pharmaceutical Medications Used
Rescue Inhaler (Albuterol)
Corticosteroid Inhaler
Daily Nebulizer Machine
Oral Steroids / Antibiotics (Frequent)
Additional Comments or Notes
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