Breathlessness Review Form

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

Breathlessness Review

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

The Avenue Surgery