COPD Questionnaire – Memorial Medical Centre

Full Name

Date of Birth

Tick the option that most applies to you

You are not troubled by breathlessness except with strenous exercise.
Your get short of breath when hurrying on level ground or walking up a slight hill.
You walk slower than most people on level ground, stop after a mile or so, or stop after 15 minutes walking at your own pace.
You stop for a breath after walking about 100 yards or after a few minutes on level ground.
You get too breathless to leave the house, or breathless when undressing.