Patient Participation Group (PPG)

The next PPG meeting is on Wednesday the 29th of January 2025 at 4:00pm if you wish to attend, please call the surgery to confirm attendance.

Need help with a non-urgent medical or admin request? Contact us online.

South Wigston Health Centre > Forms > Health Review Forms > COPD Review Form

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.

COPD 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.

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