Dyspnea Assessment Survey
Please complete this survey to help us assess your experience with shortness of breath (dyspnea). Your responses will assist in better understanding and managing your symptoms.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
How would you rate the severity of your shortness of breath?
*
None
0
1
2
3
4
5
6
7
8
9
Severe
10
0 is None, 10 is Severe
How often do you experience shortness of breath?
*
Only during strenuous activity
During moderate activity
At rest
Intermittently, regardless of activity
Other
Which activities trigger or worsen your shortness of breath? (Select all that apply)
*
Walking up stairs
Light exercise
Lying down
Talking
Exposure to allergens (dust, pollen, etc.)
Other
Do you experience any of the following symptoms along with shortness of breath? (Select all that apply)
*
Cough
Chest pain or discomfort
Wheezing
Swelling in legs or ankles
Fatigue
None of the above
Other
When did you first notice your shortness of breath?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please list any relevant medical conditions (such as asthma, COPD, heart disease) or medications you are currently taking.
Submit Assessment
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