Breathlessness Review Form - Sandy Lane Surgery

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

Name

First Last

Date of Birth

Phone

Enter Email Confirm Email

Please rate your level of breathlessness:

I am 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 am too breathless to leave the house and get breathless when getting dressed