resp_score

Bouts of Coughing

this means fits of coughing, not just occasional cough

none today

once or twice

3 or 4 times

more than 4 times

Phlegm or sputum

this relates to the colour of what you cough up

none or minimal sputum

yellowish sputum

green sputum

blood in the sputum

Sleep disturbance

whether breathing problems interfere with sleep

sleeping NOT affected by breathing problems

Breathing problems disturb my sleep

Exercise tolerance (from: MRC dyspnoea scale)

whether breathing problems are affecting your activity

I only get breathless with strenuous exercise

I get short of breath when hurrying on level ground or walking up a slight hill

On level ground, I walk slower than people of the same age because of breathlessness or have to stop for breath when walking at my own pace

I stop for breath after walking about 100 yards or after a few minutes on level ground

I am too breathless to leave the house, or I am breathless when dressing

Exercise capacity

only if a clinician has agreed a 5 minute test distance with you. Select ONE

Don't have an agreed distance plan

Can walk at least 6 laps of agreed distance

Can walk 5 laps of agreed distance

Can walk 4 laps of agreed distance

Can walk 3 laps of agreed distance

Can walk 2 laps of agreed distance

Can walk agreed distance only ONCE

Rescue inhalers

whether you needed to take an extra rescue inhaler

I have not needed any extra

I have needed extra 1, 2 times

I have needed extra 3, 4 times

I have needed extra more than 4 times

Overall feeling

Select ONE that fits best

Better than yesterday

SAME as yesterday

Worse than yesterday

Your Vital Signs readings:

these are optional - discuss with the Team

systolic Blood Pressure

diastolic Blood Pressure

Heart Rate

Oxygen saturation (%)

Peak Flow Rate (PEFR)

Temperature

Weight (kg)

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Respiratory score