Breathlessness Review Form Breathlessness Review First Name * Last Name * Email * Enter Email Confirm Email * Confirm 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 Privacy Policy This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. * I consent to the practice collecting and storing my data from this form. Send
