premierlungandsleep.com- Pulmonary Follow Up Patient Form/Questions

Pulmonary Follow Up Patient Form
Patient Name:

First NameLast Name
DOB:

MonthDayYear
Date
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
How has your breathing/cough been since your last visit?
Have you been using any inhalers, if so which ones?
Have you been on any steroids since your last visit not prescribed by Dr. Sohal?
Have you been on any antibiotics since your last visit which was not given by Dr. Sohal?
Since our last visit have you been hospitalized? If so, for what reason. What hospital?
Have you had any chest/lung imaging (CXR, CT chest), since your last visit? If so, where and when?
Please include both questionnaires for follow up patients also. Option for N/A (does not apply to me) then not required to fill out.
COPD Assessment Test (CAT)
Patients rate symptoms on a scale of 0–5, where 0 = no symptoms / not affected and 5 = worst symptoms / severely affected.
The total score is the sum of 8 questions (0–40).

Questions:
1. How often do you cough?

0

1

2

3

4

5

0 is Never , 5 is All the time
2. How much phlegm (mucus) do you have in your chest?

0

1

2

3

4

5

0 is No phlegm, 5 is full of phlegm
3. How tight does your chest feel?

0

1

2

3

4

5

0 is No tightness, 5 is Very tight
4. How breathless do you get when walking up a hill or stairs?

0

1

2

3

4

5

0 is Not breathless, 5 is Very breathless
5. How limited are you doing activities at home?

0

1

2

3

4

5

0 is Not limited, 5 is Very limited
6. How confident are you leaving your home despite your lung condition?

0

1

2

3

4

5

0 is Confident, 5 is Not confident
7. How well do you sleep?

0

1

2

3

4

5

0 is Sleep soundly, 5 is Don’t sleep soundly
8. How much energy do you have?

0

1

2

3

4

5

0 is Lots of energy, 5 is No energy at all
mMRC Dyspnea Scale
Patients are asked to choose one statement (Grade 0–4) that best describes their level of breathlessness:
Should be Empty:

Pulmonary Follow Up Patient Form

COPD Assessment Test (CAT)

mMRC Dyspnea Scale