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Vernon Street Medical Centre NHS GP Surgery in Derby

Respiratory review

Respiratory Review

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.

Blood Pressure

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Assessment

Current Weight:

Degree of breathlessness related to activities *

Not troubled by breathlessness except during strenuous exercise

Short of breath when hurrying or walking up a slight hill

Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace

Stops for breath after walking about 100m or after a few minutes on level ground

Too breathless to leave the house, or breathless when dressing or undressing

Coughing

Coughing: from 0 (I never cough) to 5 (I cough all the time) *

0

1

2

3

4

5

Phlegm

Phlegm: from 0 (I have no phlegm – mucus – in my chest at all) to 5 (My chest is full of phlegm – mucus) *

0

1

2

3

4

5

Tightness

Tightness: from 0 (My chest does not feel tight at all) to 5 (My chest feels very tight) *

0

1

2

3

4

5

Stairs

Stairs: from 0 (When I walk up a hill or one flight of stairs I am not breathless) to 5 (When I walk up a hill or one flight of stairs I am very breathless) *

0

1

2

3

4

5

Activities

Activities: from 0 (I am not limited doing any activities at home) to 5 (I am very limited doing any activities at home) *

0

1

2

3

4

5

Leaving

Leaving: from 0 (I am confident leaving my home despite my lung condition) to 5 (I am not at all confident leaving my home because of my lung condition) *

0

1

2

3

4

5

I am not at all confident leaving my home despite my lung condition

Sleep

Sleep: from 0 (I sleep soundly) to 5 (I don’t sleep soundly because of my lung condition) *

0

1

2

3

4

5

Energy

Energy: from 0 (I have lots of energy) to 5 (I have no energy at all) *

0

1

2

3

4

5

If you are human, leave this field blank.

The Vernon Street Medical Centre
13 Vernon Street
Derby
DE1 1FW

Get directions

01332 332812

The Lanes Medical Centre
147 Normanton Lane
Littleover
Derby
Derbyshire
DE23 6LF

Get directions

01332 332812

Register with the surgery

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