Please enable JavaScript in your browser to complete this form.Please indicate which of the five responses below best describes your level of breathlessness over the past week. *I get short of breath only on strenuous exerciseI get short of breath when hurrying on the level of climbing up a slight hillI walk slower than people of the same age on the level because of breathlessness, or have to stop for breath when walking at my own pace on the level.I stop for breath after walking 100 yards or after a few minutes on the level.I am too breathless to leave the house. Select the option that best matches your breathing these daysI have difficulty catching my breath *SelectNoneMildModerateSevereOn average during the past week, how much of the time did you cough? *SelectNoneHardly everA few timesSeveral timesMany timesA great many timesAlmost all the timeMy Voice difficulties restrict my personal and social life. *SelectNoneAlmost NeverSometimesAlmost AlwaysAlwaysIn general would you say your health is *SelectExcellentVery GoodGoodFairPoorOn average, during the past week, how limited were your moderate physical activities (such as walking, housework, carrying things) because of your breathing problems: *SelectNot limited at allVery slightly limitedSlightly limitedModerately limitedVery limitedExtremely limitedTotally limitedName *Surname *DOB *Email *Phone numberPlease contact meYesNoPreferred method of contact:EmailPhoneCommentSubmit Download File
