COPD Review Form

We are offering a new telephone or video consultation for COPD review. If you would like to use this service please complete the electronic form below.

First Name *

Last Name *

Email *

Date of Birth *

Please use format day/month/year e.g. 12/05/1979

Phone Number *

Your Breathlessness Review

How do you rate your level of breathlessness? *I’m not troubled by breathlessnessI get breathless when I undertake vigorous exerciseI get short of breath when hurrying or walking up slopesWhen walking I have to stop from time to time or walk slower due to breathlessnessI have to stop for breath after a few minutes of walking a short distance on level groundI’m too breathless to leave the house and get breathless when getting dressed

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

Your consent *I consent to the practice collecting and storing my data from this form.