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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.