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Church Road Surgery and Tile Cross Surgery NHS GP Surgery in Birmingham

Breathlessness review

Breathlessness Review

Patient Data

Height

Weight

Do you currently smoke?

Yes

Have you smoked in the past?

Yes

How many cigarettes did you smoke in a day?

1 to 9

10 to 19

20 to 39

40 or more

How many cigarettes do you smoke in a day?

1 to 9

10 to 19

20 to 39

40 or more

Would you like to give up smoking?

Yes

Smoking cessation support is available at the practice, through local pharmacies and via the NHS website.

If you would like to consider giving up smoking in future, please contact the surgery who will be able to offer support.

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

If you are human, leave this field blank.

Church Road Surgery
90 Church Road
Sheldon
Birmingham
B26 3TP

Get directions

0121 741 1101

Tile Cross Surgery
144 Tile Cross Road
Tile Cross
Birmingham
B33 0LU

Get directions

0121 788 2020

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