Breathlessness review

Full Name:

Phone Number:

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Please specify the ethnic group the patient belongs to: *

Please specify: *

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

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

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