Breathlessness Review

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

Please be aware that any replies from the surgery may appear in your junk or spam inbox.

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Confirmation *

I confirm I have added the most up to date phone number

If you are using a UK mobile number, please use the format 07xxxxxxxxx

Please rate your level of breathlessness: *

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

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

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