Studholme Medical Centre

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COPD exacerbations questionnaire

Please fill in the form below if asked by a member of surgery staff.

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This field is for validation purposes and should be left unchanged.

Your details

Full name(Required)

First name(s) Last name

Date of birth

Day

Month

Year

COPD flare ups

As part of your COPD management, can you let us know if you have had any COPD flare ups in the last 12 months and if so, how many?

Have you had a COPD flare up?(Required)

Yes

No

How many COPD flare ups have you had in the last 12 months?

Consent

Not for urgent medical help(Required)

Yes, I understand this form is NOT for urgent medical help

Consent(Required)

THIS FORM SHOULD ONLY BE COMPLETED BY STUDHOLME MEDICAL CENTRE REGISTERED PATIENTS.

By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.

I agree to the privacy policy.

Date published: 21st January, 2025
Date last updated: 21st January, 2025

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