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What is a COPD Management Plan, and how do you use it?

A management plan is a personal tool that helps you talk with your health care provider about your COPD. With a

management plan, you will know how and when to take your medicines, when to call your health care provider, and when

to get emergency care. A management plan also helps you track how you are doing, any concerns you may have, and any

changes in your health that are important to discuss with your doctor.

Each person’s COPD is different and so is each management plan. We hope that you will use the tools provided here to

work with your doctor to make a plan that is right for you.

There are three parts to a good management plan.

The COPD MANAGEMENT PLAN and COPD ACTION PLAN should be fi lled out with your health care provider during

your physicians visit. You should bring these with you every time you visit your doctor.

The fi rst part outlined in BLUE is called MY COPD MANAGEMENT PLAN. It is your record of general contact

information, lung function measurements, and lung health care plan. This section is also used to record your current

medications, including oxygen settings if you are using supplemental oxygen, and other health conditions. It also helps

you and your health care provider identify all of your different treatment options.

The second part in Green,Yellow and Red (like a traffi c light) is called MY COPD ACTION PLAN. This is used to help

you know what to do when your symptoms worsen. This plan is to be completed by you, with the help of your health care

provider, and should be reviewed and updated at every visit. The plan includes a comprehensive list of symptoms, but

you may experience other symptoms. If you are unclear as to the actions you should take, please contact your physician/

health care provider immediately. When listing your symptoms, the Green zone is when you are doing well, the Yellow

zone is for when you are having a bad day, and the Red zone is for when you need urgent medical care. In each zone

there is a list of symptoms and the appropriate actions you should take if you are in that zone.

The third part to a good management plan is called MY COPD REPORT CARD and it is outlined in BLUE.This is a

tracking report of how you have been feeling and should be used to help facilitate the discussion with your health care

provider. The COPD REPORT CARD should be fi lled out before every doctor visit. Be sure to take it with you! If you are

seeing your doctor for a routine visit, fi ll out the report describing how you have been feeling since your last visit. If you

are seeing your doctor for urgent care or a “fl are up” of your symptoms, fi ll out the report describing how you feel right

at that time. The Report Card also includes your general contact information and listing of your current medications. It

also has a list of detailed COPD symptoms and other health concerns you may be experiencing and want to discuss with

your physician.

Sponsored by

Instructions for COPD MANAGEMENT PLAN

COPD Flares/Other Illnesses

Since my last visit, I have been treated in an urgent care facility, emergency department, or hospital_____times

Date Reason/Treatment

Breathlessness. Check the description that best describes your breathlessness

 I am not breathless except during strenuous exercise

 I am troubled by breathlessness when I hurry on the level or up a slight hill

 I must walk slower than other people my same age or I have to stop for breath when I walk on the level

 I have to stop to catch my breath after walking about 100 yards or a few minutes walking on the level

 I am too breathless to leave the house or breathless when I dress or take a shower

Good Days and Bad Days. People with COPD have good days and bad days in terms of their energy level and

breathlessness. How do you rate yourself? Check one.

 I have all good days

 I have more good days than bad days

 I have about an equal number of good days and bad days

 I have more bad days than good days

 I have all bad days

Activity Level. How much exercise do you get? Check one.

 I get exercise on most days

 I get exercise on some days

 I get exercise occasionally

 I never get exercise

I would like to talk to the doctor about the following concerns. Check all that apply

 Medicine side effects

 Living will / medical power of attorney

 Diffi culty paying for medicines

 Marital or personal problems

 Are there other medications or procedures which might be able to help me more?

 Other:

Use the space below for additional comments

For more information visit www.lungusa.org or call 1-800-LUNGUSA (586-4872)

Sponsored by

© 2010 AstraZeneca LP. All rights reserved. 300002 4/10

For more information or to download additional copies

of the COPD Action Plan, please visit www.lungusa.org

Flat: 25.375 x 11 Finished: 8.4375 x 11

PAR # 300002

What is a COPD Management Plan, and how do you use it?

A management plan is a personal tool that helps you talk with your health care provider about your COPD. With a

management plan, you will know how and when to take your medicines, when to call your health care provider, and when

to get emergency care. A management plan also helps you track how you are doing, any concerns you may have, and any

changes in your health that are important to discuss with your doctor.

Each person’s COPD is different and so is each management plan. We hope that you will use the tools provided here to

work with your doctor to make a plan that is right for you.

There are three parts to a good management plan.

The COPD MANAGEMENT PLAN and COPD ACTION PLAN should be fi lled out with your health care provider during

your physicians visit. You should bring these with you every time you visit your doctor.

The fi rst part outlined in BLUE is called MY COPD MANAGEMENT PLAN. It is your record of general contact

information, lung function measurements, and lung health care plan. This section is also used to record your current

medications, including oxygen settings if you are using supplemental oxygen, and other health conditions. It also helps

you and your health care provider identify all of your different treatment options.

The second part in Green,Yellow and Red (like a traffi c light) is called MY COPD ACTION PLAN. This is used to help

you know what to do when your symptoms worsen. This plan is to be completed by you, with the help of your health care

provider, and should be reviewed and updated at every visit. The plan includes a comprehensive list of symptoms, but

you may experience other symptoms. If you are unclear as to the actions you should take, please contact your physician/

health care provider immediately. When listing your symptoms, the Green zone is when you are doing well, the Yellow

zone is for when you are having a bad day, and the Red zone is for when you need urgent medical care. In each zone

there is a list of symptoms and the appropriate actions you should take if you are in that zone.

The third part to a good management plan is called MY COPD REPORT CARD and it is outlined in BLUE.This is a

tracking report of how you have been feeling and should be used to help facilitate the discussion with your health care

provider. The COPD REPORT CARD should be fi lled out before every doctor visit. Be sure to take it with you! If you are

seeing your doctor for a routine visit, fi ll out the report describing how you have been feeling since your last visit. If you

are seeing your doctor for urgent care or a “fl are up” of your symptoms, fi ll out the report describing how you feel right

at that time. The Report Card also includes your general contact information and listing of your current medications. It

also has a list of detailed COPD symptoms and other health concerns you may be experiencing and want to discuss with

your physician.

Sponsored by

Instructions for COPD MANAGEMENT PLAN

COPD Flares/Other Illnesses

Since my last visit, I have been treated in an urgent care facility, emergency department, or hospital_____times

Date Reason/Treatment

Breathlessness. Check the description that best describes your breathlessness

 I am not breathless except during strenuous exercise

 I am troubled by breathlessness when I hurry on the level or up a slight hill

 I must walk slower than other people my same age or I have to stop for breath when I walk on the level

 I have to stop to catch my breath after walking about 100 yards or a few minutes walking on the level

 I am too breathless to leave the house or breathless when I dress or take a shower

Good Days and Bad Days. People with COPD have good days and bad days in terms of their energy level and

breathlessness. How do you rate yourself? Check one.

 I have all good days

 I have more good days than bad days

 I have about an equal number of good days and bad days

 I have more bad days than good days

 I have all bad days

Activity Level. How much exercise do you get? Check one.

 I get exercise on most days

 I get exercise on some days

 I get exercise occasionally

 I never get exercise

I would like to talk to the doctor about the following concerns. Check all that apply

 Medicine side effects

 Living will / medical power of attorney

 Diffi culty paying for medicines

 Marital or personal problems

 Are there other medications or procedures which might be able to help me more?

 Other:

Use the space below for additional comments

For more information visit www.lungusa.org or call 1-800-LUNGUSA (586-4872)

Sponsored by

© 2010 AstraZeneca LP. All rights reserved. 300002 4/10

For more information or to download additional copies

of the COPD Action Plan, please visit www.lungusa.org

Flat: 25.375 x 11 Finished: 8.4375 x 11

PAR # 300002