Breathlessness Review Form 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 Day Month Year PhoneEmail Enter Email Confirm Email Breathlessness ReviewPlease rate your level of breathlessness: I am not troubled by breathlessness Optional I get breathless when I undertake vigorous exercise Optional I get short of breath when hurrying or walking up slopes Optional When walking I have to stop from time to time or walk slower due to breathlessness Optional I have to stop for breath after 100 yards or after a few minutes of walking on level ground Optional I am too breathless to leave the house and get breathless when getting dressed Optional I confirm that the information provided is accurate to the best of my knowledge