Breathlessness Review Form

Please score how much you cough *

0 - I never Cough

1

2

3

4

5 - I cough all the time

Please score how much phlegm (mucus) you have in your chest *

0 - I have no phlegm (mucus) in my chest at all

1

2

3

4

5 - My chest is completely full of phlegm (mucus)

Please score how tight your chest feels *

0 - My chest does not feel tight at all

1

2

3

4

5 - My chest feels very tight

Please score your breathlessness walking up a hill or a flight of stairs *

0 - When I walk up a hill or one flight of stairs I am not breathless

1

2

3

4

5 - When I walk up a hill or one flight of stairs I am very breathless

Please score how limited your home activities are *

0 - I am not limited doing any activities at home

1

2

3

4

5 - I am very limited doing activities at home

Please score your confidence in leaving your home *

0 - I am confident leaving my home despite my lung condition

1

2

3

4

5 - I am not at all confident leaving my home because of my lung condition

Please score your sleep *

0 - I sleep soundly

1

2

3

4

5 - I don't sleep soundly because of my lung condition

Please score your energy levels *

0 - I have lots of energy

1

2

3

4

5 - I have no energy at all

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.

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