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01642 618170
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NHS 111
Queens Park Medical Centre
Farrer St
Stockton-on-Tees
TS18 2AW
CQC Inspected and Rated
Good
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Queens Park Medical Centre
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Breathlessness Review
If you have been advised by the surgery to submit breathlessness review on a regular basis please use this form.
Full Name:
Date of Birth:
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
I confirm that the information provided is accurate to the best of my knowledge.
I confirm that I am currently within the UK at the time of sending my enquiry.