Dyspnea Management Questionnaire Form
Please complete the Dyspnea Management Questionnaire Form to help us better understand your experiences and management of breathlessness.
Full Name
*
First Name
Last Name
Age
*
How often do you experience breathlessness?
*
Daily
Several times a week
Once a week or less
Rarely
How would you rate the severity of your breathlessness at its worst?
*
No breathlessness
0
1
2
3
4
5
6
7
8
9
Worst imaginable
10
0 is No breathlessness, 10 is Worst imaginable
What activities typically trigger your breathlessness? (Select all that apply)
*
Walking
Climbing stairs
Talking
Lying flat
Emotional stress
Other
How does breathlessness affect your daily life?
*
Which of the following strategies do you use to manage breathlessness? (Select all that apply)
*
Pursed-lip breathing
Resting during activity
Using a fan
Medication
Relaxation techniques
Other
Are you currently using any prescribed treatments for breathlessness?
*
Yes
No
If yes, please list your current treatments (if none, leave blank)
Do you have any additional comments or concerns about your breathlessness?
Email address (optional, for follow-up)
example@example.com
Submit
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