COPD Tests Worksheet

Below is a list of tests and assessments that you need. Provide the information requested to see how well you are managing your COPD.

Influenza vaccine

I had a flu vaccine on _________. People with COPD are more likely to get the flu. Make sure that you have a flu shot once a year, preferably in October or November.

Pneumonia vaccine

I had a pneumonia vaccine on _________. A pneumonia vaccination is given one time, but should be repeated if you are at least 65 and five years or more have passed since your vaccination.


The date of my next spirometry is _________. This is a simple lung-function test done in a health care provider’s office or in a hospital. This test should be done once a year or as recommended by your provider.

Action plan

I talked with my provider about my action plan on _________. Work with your provider to develop a written plan and a list of things to do when your symptoms change. Ask your provider to review this plan at least once a year.

Nutritional assessment

Good nutrition and maintaining a normal body weight are important for people with COPD. Your provider may refer you for a nutritional assessment if you are too thin or too heavy.


I talked with my provider about exercises I can do on _________. It is important to keep your lungs in strong condition to help you maintain a normal activity level.

Pulmonary education programs

Your provider may recommend a pulmonary education program that will teach you how to exercise safely, adapt your home environment and get the best outcome from your breathing therapies.


I talked with my provider about quitting smoking on _________. Smoking is the single largest contributor to lung disease and other serious diseases.

Although these are suggested guidelines for care, please check with your benefits plan for coverage.


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