COPD Risk Assessment

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* 1. During the past 4 weeks, how much of the time did you feel short of breath?

All the time

Most of the time

Some of the time

A little of the time

None at all

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* 2. Do you ever cough up any "stuff", such as mucus or phlegm?

Yes, every day

Yes, most days a week

Yes, a few days a month

Only with occasional colds of chest infections

No, never

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* 3. Please select the answer that best describes you in the past 12 months. I do less than I used to because of my breathing problems.

Strongly agree

Agree

Unsure

Disagree

Strongly disagree

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* 4. Have you smoked at least 100 cigarettes in your ENTIRE LIFE?

Yes

No

Don't know

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* 5. Have you spent significant time around second-hand smoke, or have you worked long term in environments where there is dust, pollutants, smoke, and/or airborne particles?

Yes

No

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* 6. How old are you?

18-34

35-49

50-59

60-69

70+

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* 7. OPTIONAL: Please provide the following information. We do NOT share names or emails for any reason. Providing this information is optional and is only to provide you the option of receiving free resources and information in the future.

First Name

Last Name

Email

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* 8. Can we follow up with you via email? We would simply provide free information and resources about COPD. We do not share your information with ANYONE for ANY REASON.

Yes

No

After receiving your score, be sure to scroll down to the bottom of the page and click the "DONE" button for important information.