COPD Action Plan
by Dr. John Yap. The COPD action plan can be customized to include your name, office address, phone number, etc. Simply go to e-forms and edit the sections to individualize the form. Using ctrl-F will usually open a "find" function. Search for the generic sections and substitute your personal information. If you make a mistake, just reload the form and start again. Or you can contact me and I will customize it with your information.
COPD.html
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<title>COPD Care Plan</title>
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<h1>COPD Care Plan</h1>
<p style="border-style: double none none; border-color: rgb(0, 0, 0) -moz-use-text-color -moz-use-text-color; border-width: 1.1pt medium medium; padding: 0.02in 0in 0in; margin-bottom: 0in;" align="center"></p>
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<form name="form1" method="post" action="">
<table class="head">
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<td valign="top" width="50%">
<input name="C1" value="ON" type="checkbox">Dr. A.B. Cee<br>
<input name="DrOther" type="checkbox"><input name="DrOtherText" class="noborder normaltext" style="width: 200px;" type="text"><br>
</td>
<td align="right" valign="top" width="50%">Office Address <br> City, Prov, Postal Code <br>
Phone 555-555-5555<br>
Fax
555-555-5554
</td>
</tr>
</tbody></table>
<p>
<input name="date" size="20" oscardb="Today" class="noborder" type="text">
<br>
<input name="name" size="30" oscardb="patient_name" class="noborder" type="text">
</p>
<p><b>You have been diagnosed with COPD (chronic obstructive pulmonary disease)</b><br>
COPD has 2 states:<br>
1. You are stable. You are not short of breath, can do daily
activities, can cough up mucus easily, sleep well, and are able to
exercise. Or.....<br>
2. You are having a flare up.</p>
<p><b>How to tell if you are having a flare up</b><br>
A flare up may occur after you get a cold, get run down, are exposed to air pollution, or very hot/cold<br>
weather. There are 3 things that define a flare up:<br>
1. Increased shortness of breath from your usual level.<br>
2. Increased amount of sputum from your usual level.<br>
3. If your sputum changes from its usual colour to yellow, green, or rust colour.<br>
You may also feel a change in mood, fatigue or low energy prior to a flare-up.<br></p>
<p><b>If 2 or more of these symptoms persist for 24 hours or more, do the following:</b><br>
<input name="X1" value="ON" type="checkbox">Take your rescue inhaler 2-4 puffs as needed (up to 4-6 times per day) for shortness of breath.<br>
<input name="X2" value="ON" type="checkbox">Call your family doctor immediately for a check up and medication review.<br>
<input name="X3" value="ON" type="checkbox">Use prescribed prednisone for a COPD flare up. Take <input name="PrednisoneDose" class="noborder normaltext" style="width: 22px;" type="text">
mg per day for <input name="PrednisoneDays" class="noborder normaltext" style="width: 22px;" type="text">days.<br>
<input name="X4" value="ON" type="checkbox">Use prescribed antibiotic for a COPD flare up. <br>
Take <input name="AntibioticType" class="noborder" style="width: 125px; text-align: center;" type="text"> <input name="AntibioticDose" class="noborder" style="width: 45px; text-align: center;" type="text">
mg <input name="Dosing" class="noborder" style="width: 60px; text-align: center;" type="text">per day for <input name="AntibioticDays" class="noborder" style="width: 22px; text-align: center;" type="text">days.<br>
<input name="X5" value="ON" type="checkbox">Contact your doctor if you feel worse or do not feel better after 48 hours of treatment.<br>
<input name="X6" value="ON" type="checkbox">Other:<br>
<textarea name="reason" cols="80" rows="4"></textarea><br>
</p>
<p><b>If you are extremely breathless, anxious, fearful, drowsy or
having chest pain, call 911 for an ambulance to take you to the
Emergency Department</b></p>
<p class="bold">
Physician Signature:</p>
<p class="bold">
Patient Signature:
(optional)</p>
<p class="hide">
Subject: <input name="subject" size="40" type="text"><br>
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<input value="Submit" name="B1" class="button" type="submit">
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