Lung Function Assessment

Welcome to your Lung Function Assessment

At Siesta Sleep & Respiratory your privacy is important to us!

We would like to reassure you that your lung function assessment responses will be kept confidential and will not be misused or made public.

Your Name Your Email Your Phone Number

Do you ever experience shortness of breath or have trouble breathing?

Yes No

Do you ever hear a 'wheezing' sound when you breathe?

Yes No

Do you have a cough that won't go away?

Yes No

Do you suffer from recurrent chest infections?

Yes No

Do you ever have chest discomfort or pain when breathing in or out?

Yes No

Do you feel a decreased ability to exercise due to your breathing?

Yes No

Do you suffer from any allergies?

Yes No

Are you a smoker (or ex-smoker)?

Yes No

Do you ever cough up blood or mucus?

Yes No

10.

Have you ever been told that you have any of the following conditions: Asthma, Bronchitis, Bronchiectasis, COPD, Emphysema or Lung Cancer?

Yes No

11.

Do you currently (or in the past) work with asbestos?

Yes No

12.

Your gender

Female

Male

Other

13.

Your post code

14.

Do you provide consent for one of Siesta Sleep & Respiratory's health professionals to contact you in response to this lung function assessment?

Yes No

Time is Up!

Time's up