Pulmonary Patient Forms

Name

First NameLast Name
Pulmonary Rehabilitation Self-Assessment Form
Shortness of Breath: Please check the statement that best fits your daily level of shortness of breath.*

0 No trouble with shortness of breath except with strenuous exercise such as running or carrying 25 lbs. while walking up hill.1 You feel short of breath while walking on a flat level of ground in a hurry or walking up a slight hill.2 You walk slower than others of the same age or have to stop to catch your breath while walking on level ground because of shortness of breath.3 You have to stop to catch your breath after walking a short distance (less than 100 yards, less than the length of a football field) or after walking for just a few minutes on level ground.4 You are too breathless to leave the house or are too breathless to dress and fix meals.

Rows	Not at all (0)	Several days (1)	More than half the days (2)	Nearly every day (3)
Little interest or pleasure in doing things.
Feeling down, depressed, or hopeless.
Trouble falling/staying asleep, sleeping too much.
Feeling tired or having little energy.
Poor appetite or overeating.
Feeling bad about yourself, or that you are a failure, or have let yourself or your family down.
Trouble concentrating on things, such as reading the newspaper or watching TV.
Moving or speaking so slowly that other people could have noticed. Or the opposite; being so fidgety or restless that you have been moving around more than usual.
Thoughts that you would be better off dead or of hurting yourself in some way.

COPD Assessment Test