Measure of Breathlessness Review Form

If you have been advised by the surgery to submit a breathlessness review on a regular basis please use this form.

Last Updated: 08/11/2023

Your Details

Surname *

First Names *

Date of Birth *

Phone Number - Mobile and/or home *

Email Address

Breathlessness Review

How do you rate your level of breathlessness? Please select one of the options below which best describes your breathlessness currently. *

No symptoms and no limitation in ordinary physical activity (NYHAC - Class 1)

Mild symptoms and slight limitation during ordinary activity (NYHAC - Class 2)

Significant limitation in activity due to symptoms. Comfortable only at rest (NYHAC - Class 3)

Severe limitations, symptoms even while at rest (NYHAC - Class 4)

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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Measure of Breathlessness Review Form

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