Breathlessness Review

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

If you are human, leave this field blank.

About You

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

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

Important -

If you are aged 50 or over or are classed as at high risk from the corona virus, and have not yet received your first dose of vaccine, please contact the surgery to arrange an appo... Find out more

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Breathlessness Review