Breathlessness Review Form

If you have been advised by the surgery to submit a breathlessness review on a regular basis please use this form.

Name Optional

This field is for validation purposes and should be left unchanged.

Name Required

Date of Birth Required

Telephone Optional

Email Required

How do you rate your level of breathlessness? Required

I’m not troubled by breathlessness

I get breathless when I undertake vigorous exercise

I get short of breath when hurrying or walking up slopes

When walking I have to stop from time to time or walk slower due to breathlessness

I have to stop for breath after a few minutes of walking a short distance on level ground

I’m too breathless to leave the house and get breathless when getting dressed

Additional Information