Breathlessness Review Form Breathlessness Review First Name * Last Name * Email * Date of birth * Please use format day/month/year e.g. 12/05/1979 Phone Number * Your 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 Terms & Conditions By using the forms contained here you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that because of the nature of the Internet we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of communicating with the practice. Personal information is not stored on this system but may be used to update your records with the practice. Send If you are human, leave this field blank.