COPD Questionnaire Sample

The primary data would be a questionnaire. It includes eight sections that contain a personal overview of the client as well as medical information. It will be administered once at the beginning of Breathe Easy, but the last few sections will be looked over at the end of the program to determine if the client reached his/her goal and desired outcome. This questionnaire is adapted from the needs assessment from Living Well with COPD, a similar program9. This questionnaire went out to all of those in their program, but a specific population was not addressed. With Breathe Easy, the population is people aged 21- 75 who are at risk or diagnosed with COPD. Therefore, modifications will be made for this program. Each attendee will receive this questionnaire

It asks for name, date of birth, marital status, education, occupation, and current medications. As stated previously, education and other social factors often are risk factors for COPD. It also inquires if diagnosed with COPD and if so, how many hospital stays and/or visits. In this section, it also asks for respiratory status. Is there dyspnea on exertion, a smoking history, and/or any symptoms? Since this program is for individuals diagnosed and those at risk, all of these factors are important. These are the basics to identify and help understand the client as a whole. Therefore, this portion is highly significant.

Section two includes referral information. It asks the clients current understanding of COPD and why they were referred to this program. Similarly, it also asks what their expectations of undergoing this program are. Breathe Easy is designed to help educate and inform, so this section will be looked over at the end to see if their expectations were met and if their understanding of COPD has changed and how. This section is critical as well since it provides a baseline of their understanding of COPD and their

It also asks if they feel in control of their illness. This will be helpful with section four to help set a specific goal. Section six is a summary where they answer what issues they face in regards to themselves and family. What concerns do they have? Are they nervous about this program? All uncertainties will be listed here. This will help them more mentally. Likewise, section seven is the intervention portion. The patient will write down what they plan to do differently to make lifestyle changes to prevent and/or manage COPD. How will they go about their uncertainties? What needs to change? This is important for the patient to visualize their goals and realize it can be a