Required field(s) are indicated by * Breathlessness Review Breathlessness Review If you are human, leave this field blank. You have not agreed to share your data with this website, please either try to login again and grant the website access or alternatively fill out the form below. To proceed, you can either use NHS login, which will retrieve your details and will pre-populate the form below: Continue to NHS login or continue without NHS login and complete the form below: About you Your First Name(s): * As it appears on your passport. Your Last Name: * As it appears on your passport. Postcode: * The one used to register with your GP. Your Date of Birth: * Your date of birth is required to verify your identity. Sex: * Male Female Other As on your medical record. As on your medical record. Your Phone Number: * This phone number will be used for all correspondence relating to this request. Your Email: * This email address will be used for all correspondence relating to this 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 Breathlessness Review 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 Submit