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COPD SCREENER QUESTIONNAIRE

Do you know what (COPD) chronic obstructive pulmonary disease is? This chronic lung disease is a serious cause of illness; however, many people have it and don't even know it. Take this short questionnaire to help learn if you could potentially have COPD and need further evaluation.

Do you cough several times most days? *YesNo

Do you bring up phlegm or mucus most days? *YesNo

Do you get out of breath more easily than others your age? *YesNo

Are you older than 40 years? *YesNo

Are you a current smoker or an ex-smoker? *YesNo

From a scale from 0 to 5, you have scored:

Lung Sleep Institute Medical Disclaimer *

I acknowledge the Screener is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on the Screener.

CONTACT US FOR QUESTIONS OR APPOINTMENTS

First Name *

Last Name *

Date of Birth *

Month

Day

Year

Email Address *

Phone Number *

Message *0 / 180

I Agree *

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Communications through our website or via email are not encrypted and are not necessarily secure. Use of the internet or email is for your convenience only, and by using them, you assume the risk of unauthorized use.

By submitting a form you hereby agree to hold Lung Sleep Institute at Millennium Physician Group, its doctors and affiliates, harmless from any hacking or any other unauthorized use of your personal information by outside parties

Contact Us

239-315-7123

239-315-7122 (fax)

6376 Pine Ridge Rd. Unit 440
Naples, Florida 34119

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