Flu and COVID Boosters Autumn 2024

Dear Patient, We will be starting our vaccine programme at the practice from October. We will be offering Flu and COVID vaccines to all those eligible. We will be able to administer these in the same sitting. We will contact those who are eligible in due course to start inviting our patients in for vaccination.

Gade Surgery > Forms > Health Review Forms > Breathlessness Review Form

Breathlessness Review Form

Breathlessness Review

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 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 a few minutes of walking a short distance on level ground

I’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.

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

Flu and COVID Boosters Autumn 2024

Breathlessness Review Form

Your Breathlessness Review

Privacy Policy

Health A-Z

Live Well

Medicines Guide

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Witton House