COPD Interview form
this form is for respiratory care students to interview a patient
COPD Interview form
COPD Management Assessment / Interview
Interview a patient during your clinic / hospital days
Date of interview
1. Has a healthcare professional ever told you that you have COPD, Chronic Bronchitis, or Emphysema?
2. How long ago were you diagnosed with this condition? Or at what age?
3. In addition to COPD, do you have any other health conditions?
Other ailments / history
4. Who usually manages your COPD?
primary care physician
5. How often do you see your physician for your COPD
Twice a year
Several times / year
More that 4 times / year
6. Have you ever had a breathing test call spirometry?
IF yes, did your physician review the results with you?
7. Do you have a written COPD action plan or treatment plan that was developed by a health care provider.
IF yes, when was it last updated
8. During the last 12 months, have you gone to the hospital ER or been admitted to the hospital because of your COPD?
9. Have you ever participated in a pulmonary rehabilitation program?
IF yes, was it inpatient or outpatient? How long ago?
10. Which of the following COPD symptoms would you say you experience most days?
Shortness of breath
Sputum / mucous production
11. Is there anything that makes your COPD worse?
12. If you feel anxiety or panic dure to shortness of breath, what do you do?
Use relaxation techniques
Practice breathing exercises (pursed lip,etc)
Other treatments to relieve shortness of breath
13. Have you ever had a lung infection?
14. Are you aware of the possible symptoms of lung infection
IF yes, list symptoms
15. Do you take your resuce medication to cathc your breath when breathing suddenly gets worse?
16. do you take maintenance medication to manage your COPD?
List COPD meds
17. Do you take your maintenance meidcations every day
IF no or sometimes, why not
can' t afford them
forget to refill
I do not think I need them everyday
18. Do you use oxygen at home?
IF yes, how much oxygen?
19. Do you currently smoke?
yes, but quit
If you smoked, for how long and how many packs per day?
Do you have an exercise routine?
IF yes, describe routine
Do you get an annual flu shot?
IF no, why not?
END OF INTERVIEW
Demographics and Chart Review
Research information from the patient's medical record.
What is patient's gender?
What is the patient's age
What are the patient's home meds?
What are the patients admission medications?
Other pertinent information from the chart
This section is for you to reflect on the experience of the interview
How did you feel interviewing the patient? Please explain
Did you feel the patient was being honest with you? Please explain
Did you gain useful information in how a patient perceives information? please explain
Overall impression of assignment: what insight have you gained from this?
Submit this form when completed. Thank you
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