How do you rate your level of breathlessness?

• 0 - I’m not troubled by breathlessness at all even on strenuous exercise
• 1 - I only get breathless when I undertake vigorous exercise
• 2 - I get short of breath when hurrying on a level or walking up a slight hill
• 3 - I walk slower than most people on the level but can walk for a mile or so
• 4 - I have to stop for breath after a few minutes of walking a short distance on level ground
• 5 - I’m too breathless to leave the house and get breathless when getting dressed

Thinking about your cough use the scale below to score yourself

• 1 - I never cough
• 2
• 3
• 4
• 5 - I cough all the time

hinking about phlegm (mucus) on your chest use the scale below to score yourself

• 0 - I have no phlegm on my chest at all
• 1
• 2
• 3
• 4
• 5 - My chest is full of phlegm

Thinking about chest tightness use the scale below to score yourself

• 0 - My chest does not feel tight at all
• 1
• 2
• 3
• 4
• 5 - My chest feels very tight

Thinking about your exercise ability use the scale below to score yourself

• 0 - When I walk up a hill or a flight of stairs I am not out of breath
• 1
• 2
• 3
• 4
• 5 - When I walk up a hill or a flight of stairs I am completely out of breath

Thinking about limits to activities use the scale below to score yourself

• 0 - I am not limited to doing any activities at home
• 1
• 2
• 3
• 4
• 5 - I am completely limited to doing all activities at home

Thinking about leaving the house use the scale below to score yourself

• 0 - I am confident leaving my home despite my lung condition
• 1
• 2
• 3
• 4
• 5 - I am not confident leaving my home at all because of my lung condition

Thinking about your sleeping use the scale below to score yourself

• 0 - I sleep soundly
• 1
• 2
• 3
• 4
• 5 - I do not sleep soundly because of my lung condition

Thinking about your energy levels use the scale below to score yourself

• 0 - I have lots of energy
• 1
• 2
• 3
• 4
• 5 - I have no energy at all

How often do you need to use your Ventolin (blue) inhaler?

• Rarely such as when undertaking strenuous exertion/unwell
• 2-3 times a week
• Once or twice a day
• Every couple of hours

Do you smoke?

• Never
• Stopped within the last year
• Stopped >1yr ago
• 1-9 per day
• 10-19 per day
• 20-39 per day
• 40+ per day

Please state your current smoking status

• Trivial Smoker <1 per day
• Trying to quit (wanting help)
• Pipe Smoker
• Cigar Smoker
• Vape