Breathlessness Review

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.

Please only use this form if you have been asked to as part of your long term condition review. If you do not have a long term condition please submit an eConsult form.

About You

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

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

Tell us whether you accept cookies

Breathlessness Review