Date:  <<Miscellaneous:Date (long)>>(Ask your doctor to review each year with your GPMP)

Patient Name: <<Patient Demographics:Full Name>>	Date of Birth: <<Patient Demographics:DOB>>	
GP Name: <<Doctor:Name>>	GP Phone: <<Doctor:Phone>>	
Health Worker Name: <<Health Worker Name>>	Health Worker Phone: <<Health Worker Phone>>	

Feeling your usual self (easy to breathe)	
Feeling your usual self	Taking usual medicine	Have lots of energy	
Sleeping well	No headaches, not dizzy	Usual amount of phlegm	
ACTION: Continue taking your usual medicines as listed below.	
Annual Influenza Immunization - Date: <<Influenza date given>>	
Last Pneumoccal Immunisation - Date: <<Pneumococcal date given>>	
My usual medicines	Colour of device	How many puffs or tablets	How often	
Oxygen	Yes/No	Setting or 1/min	hrs/day	
<<Clinical Details:Medication List>>
Feeling a little bit sick (harder to breathe)	
Harder to breathe than usual	More phlegm or thicker than usual	Loss of appetite	
Fever	A change of colour of phlegm	Not sleeping well	
More coughing	Taking more reliever medicine	Not much energy	
ACTION: Follow plan below for extra medicines. Plan your day, get rest, relax, use breathing techniques, huff and cough to clear phlegm as required. Consider contacting your Health Worker/Nurse or Doctor. 	
My extra medicine	Colour of device	How many puffs or tablets	How often	
<<ExtraMedicine1>>	<<ExtraMedicine1-Colour>>	<<ExtraMedicine1-Dose>>	<<ExtraMedicine1-Frequency>>	
<<ExtraMedicine2>>	<<ExtraMedicine2-Colour>>	<<ExtraMedicine2-Dose>>	<<ExtraMedicine2-Frequency>>	
<<ExtraMedicine3>>	<<ExtraMedicine3-Colour>>	<<ExtraMedicine3-Dose>>	<<ExtraMedicine3-Frequency>>	
Medicine	Strength	Tablets each day	No. of days	
Prednisolone*:	<<Prednisolone Strength>>	<<Prednisolone tablets per day>>	<<Days on Prednisolone>>	
Antibiotics*: <<Antibiotic Name>>	<<Antibiotic Strength>>	<<Antibiotic doses per day>>	<<Days on Antibiotic>>	
* GP to fill in if prescribed. Identify if reducing schedule is required.

Not Good (trouble breathing and wheezing)	
Very short of breath at rest	Drowsy	|Blood in your phlegm	
High fever	Chest Pain	|Difficulty sleeping/woken easily	
Confused, slurring of speech	Afraid/scared	|Swollen Ankles	
ACTION: Phone an Ambulance 000	|ACTION: Contact Emergency Doctor	
CALL AMBULANCE 000 IMMEDIATELY	
Show them this plan and say you have a flare up of your COPD	
CAUTION: Ambulance/Paramedics: CO2  Retainer : <<CO2 Retainer>>	
Resources available via Lung Foundation Australia - Contact to order your copy. 
Better Living with COPD - Patient Guide
Better Living with Your Lung Disease DVDs
1800 654 301 | www.lungfoundation.com.au | enquiries@lungfoundation.com.au