PATIENT DETAILS
Preliminary diagnosis of asthma or COPD
Age in years:
Height (cm):
Male
Female
SPIROMETRY DATA
Pre-bronchodilator
ASTHMA VS COPD
Beeh Questionnaire
DDQ Questionnaire
Pre-BD
Predicted
% Predicted
FEV
1
(l)
FVC (l)
Age at onset of symptoms
<20 years
20 to 40 years
40 to 60 years
>60 years
FEV
1
/FVC (%)
Atopy status
Yes
None
PEFR (l/sec)
Smoked
packyears
Not a smoker
0 to 20 packyears
20 to 40 packyears
>40 packyears
FEF 25-75% (l/sec)
Cough characteristics
Dry cough
No cough
Productive cough
Post-bronchodilator
Post-BD
% Predicted
% Change
FEV
1
(l)
Points
=
FVC (l)
FEV
1
/FVC (%)
PEFR (l/sec)
FEF 25-75% (l/sec)
= required
© 2005 ALF, v1.7