Breathlessness Review Form - Highbury Grange Medical Practice

Breathlessness Review

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

Name

First Last

Please enter your full legal name

Date of Birth

Please enter your Date of birth in the format DD/MM/YYYY

Phone Number Optional

Email Address

Please complete the form below

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