Breathlessness Review Form

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

Last Updated: 23/10/2019

Your Details

Name

Date of Birth
For example, 15 3 1984

Day

Month

Year

Phone Number (optional)

Email Address
Breathlessness Review

HOW DO YOU 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 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

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA.

I consent to the practice collecting and storing my data from this form.

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