Breathlessness Review

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

Section

Please rate your level of breathlessness:

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 100 yards or after a few minutes of walking on level ground

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

Please note that the details you give will be used to update your medical records. If your correct contact information is not entered we will not be able to respond to you.

I confirm that the information provided is accurate to the best of my knowledge.

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Breathlessness Review