Breathlessness Review

Due to the current crisis we may take a little longer to deal with requests, we aim to deal with any queries as soon as possible, prescriptions and sick notes will be issued within 5 days and backdated where required.

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

If you are human, leave this field blank.

About You

Full Name: *

Phone Number: *

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

Is there any other information that you feel the Clinician should know?

I confirm that the information provided is accurate to the best of my knowledge

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Breathlessness Review