Breathlessness Review

Which surgery are you registered with? *

Russell Street Surgery

Burghfield Health Centre

Coley Park Surgery

Are you completing this form on behalf of:

Yourself

Someone else (e.g. a child or dependent)

About you

Your First Name(s): *

First Name(s) as appears on your passport.

Your Last Name: *

Last Name(s) as appears on your passport.

Your Date of Birth: *

Your date of birth is required to verify your identity.

Sex: *

Male

Female

Other

As on your medical record.

Your Phone Number: *

The practice may use this number to contact you about your request.

Your Email: *

This email address can be used to contact you about your request. Please be aware that if you have given anyone else access to your email account they may see responses sent to you.

Please continue completing the form below

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

It has been found to be beneficial for patients with breathlessness to undertake Pulmonary Rehabilitation programmes. You may already have done so. It consists of education about the disease and assistance with exercise.

Please select an option relating to the Pulmonary Rehabilitation programme:

I am interested in taking part in the programme

I have done the programme over 18 months ago and would like to do it again

I have already done the programme within the last 18 months

I am not interested at the current time

BMI

Height (in Meters): *

eg. 1.75

Weight (in Kilograms): *

eg. 60.6

BMI:

For more information, please visit NHS: Healthy Weight.

*

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