Breathlessness Review

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

You must be registered with this practice to submit this form. 

Breathlessness Review

Breathlessness Review

About You

Please use this date format: DD/MM/YYYY.

Breathlessness Review

Please rate your level of breathlessness: *

Please can you update us about your smoking

Do you currently smoke? *
Are you an ex smoker? *

If you currently smoke the advice is to reduce and stop. Local services that can help you can be found at www.smokefreelifeoxfordshire.co.uk

*
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