BREATHING DIFFICULTY

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If you have difficultly in breathing, please fill following details which will help the doctor to analyse your problem better.

Please write your name and institution ID ,if any?

for how many days now this problem is?Is it a long problem?

< one week

<one month

Few months

Few years

Clear selection

Is this the first episode or repeated episodes? If repeated, how many times per year?

Is breathing difficulty at rest or while walking

At rest

while lying down

While walking

Is there any of the following also?

Cough

Chest pain on walking;relief with rest

Wheezing

Swelling feet

Raised blood pressure

Diabetes

Past history of chest disease like treated Tuberculosis

Known case of heart disease

Smoking

Are you a known case of asthma

Kidney problem

If you have fever how much is maximum temperature?

>104

101-104

99-101

<99

Clear selection

any other information you want to submit

Submit

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