COPD Assessment | Fidelis Care

This short survey will only take a few minutes to complete and will help us monitor how you are doing. If you are a caregiver, please answer the questions as they relate to the Fidelis Care member identified below.

Name

First Last

How would you rate your level of overall health and well-being?*

Are you able to follow your treatment plan as directed by your doctor?*

Yes
Somewhat
No

Please let us know why?*

I can't afford the medication
I don't like the side effects
I forget
No desire
I am having trouble contacting my doctor
It will not make a difference in my health state
I don’t know what my treatment plan is
Other

Why else can't you follow your treatment plan?*

Are you able to engage in regular physical activity / exercise?*

Yes (3 to 5 hours a week or more)
Somewhat (Up to 2 hours and 30 minutes a week)
No (Not active)

Are you experiencing shortness of breath more often than usual?*

No
Somewhat
Yes

Do you understand how to use your medications?*

Yes
Somewhat
No

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Health Rating Score

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Call CC

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Call Provider

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region

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SendEmail

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status

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