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COPD Checklist

COPD (Chronic Obstructive Pulmonary Disease) includes chronic bronchitis and emphysema. Sharing even the small details about your COPD with your doctor can make a difference. The more details you share about your COPD, the better you can partner with your doctor. So, fill out this form and give it to your doctor at your next appointment. It may help you have a more informed conversation about your COPD.

Since your last doctor's visit, have you... (Check all that apply)



Which of the following best describes your breathing lately? (Check all that apply)

On the back of this form, please list all the medicines you are currently taking, including herbal and non-prescription products, and list any questions you have for your doctor. Take this completed form to your doctor.