Breathlessness Review Breathlessness Review If you are human, leave this field blank. About You Full Name: * Date of Birth: * Please use this date format: DD/MM/YYYY. Phone Number: Email Address: * Any responses we send will go to this email address. 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
