Breathlessness Review Form If you have been invited by the practice to submit a breathlessness review, please complete this 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 Check and Send
