Breathlessness Review

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

Breathlessness Review

Breathlessness Review

Patient Data

Do you currently smoke?
Have you smoked in the past?
How many cigarettes did you smoke in a day?
How many cigarettes do you smoke in a day?
Would you like to give up smoking?

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:
*