Breathlessness Review If you have been advised by the surgery to submit 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 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