Breathlessness Review

Section

Have you received a letter advising you to complete this review?

Yes

No

Please specify requester and date of letter:

Please use date format DD/MM/YYYY.

Patient Status

Height:

Weight:

Blood Pressure

Systolic "Higher"

Diastolic "Lower"

Heart Rate

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

When are you available to take a call in the next few weeks?

Text/Email Consent

The practice can send you a text message or email with your appointment time and appointment reminder. *

I agree to the practice sending me text messages and emails including appointment times and appointment reminders

I do not agree to the practice sending me text messages and emails including appointment times and appointment reminders

Summary Care Record

You have the choice of what information you would like to share and with whom. Authorised healthcare staff can only view your SCR with your permission. The information shared will solely be used for the benefit of your care. Please select one of the options below:

Consent:

Express consent for medication, allergies and adverse reactions only.

Express consent for medication, allergies, adverse reactions and additional information - further medical information includes your illnesses and health problems, operations and vaccinations you have had in the past, how you would like to be treated (such as where you would prefer to receive care), what support you might need and who should be contacted for more information about you.

Express dissent for Summary Care Record (opt out) - you do not want any information shared with other healthcare professionals involved in your care.

Are you sure? If you do not allow us to include additional information in your Summary Care Record, your care may be harmed if you get seriously ill.

*

I confirm that the information provided is accurate to the best of my knowledge

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Breathlessness Review