Clinical COPD Questionnaire

Please circle the number of the response that best describes how you have been feeling during the past week. (Only one response for each question)
On average, during the past week, how often did you feel:	Never	Hardly ever	A few times	Several times	Many times	A great many times	Almost all the time
Short of breath at rest?	0	1	2	3	4	5	6
Short of breath doing physical activities?	0	1	2	3	4	5	6
Concerned about getting a cold or your breathing getting worse?	0	1	2	3	4	5	6
Depressed (down) because of your breathing problems?	0	1	2	3	4	5	6
In general, during the past week, how much of the time:
Did you cough?	0	1	2	3	4	5	6
Did you produce phlegm?	0	1	2	3	4	5	6
On average, during the past week, how limited were you in these activities because of your breathing problems:	Not limited at all	Very slightly limited	Slightly limited	Moderately limited	Very limited	Extremely limited	Totally limited/or unable to do
Strenuous physical activities (such as climbing stairs, hurrying, doing sports)?	0	1	2	3	4	5	6
Moderate physical activities (such as walking, housework, carrying things)?	0	1	2	3	4	5	6
Daily activities at home (such as dressing, washing yourself)?	0	1	2	3	4	5	6
Social activities (such as talking, being with children, visiting friends/relatives)?	0	1	2	3	4	5	6

CCQ Questionnaire calculation of scores:

CCQ total score = (item 1 + 2 + 3 + 4 + 5 + 6 + 7 + 8 + 9 + 10)/10
Symptom = (item 1 + 2 + 5 + 6)/4
Functional state = (item 7 + 8 + 9 + 10)/4
Mental state = (item 3 + 4)/2.

Reproduced with permission from: van der Molen T, Willemse BW, Schokker S, et al. Development, validity and responsiveness of the Clinical COPD Questionnaire. Health Qual Life Outcomes 2003; 1:13. Copyright © 2003 Thys van der Molen. The Clinical COPD Questionnaire is copyrighted. It may not be changed, translated, or sold (paper or software) without permission of Thys van der Molen. The CCQ is available for all clinical purposes without charge in 62 languages on www.ccq.nl.

Graphic 86308 Version 3.0