Shortness of Breath Questionnaire
What a shortness of breath questionnaire asks, the areas it covers, and sample questions for practice staff.
The Woolcock Breathlessness Clinic's shortness of breath questionnaire records how long breathlessness has lasted, what brings it on, walking distance, and health history. It's also called a breathlessness history or an exertional dyspnea questionnaire.
Shortness of breath questionnaire, handled by the AI Doctor avatar
AI Doctor, a real-time AI healthcare assistant avatar, asks the questions on a shortness of breath questionnaire in the patient's own language, strictly following the practice's instructions.
- Intake before the visit. Patients answer online before they arrive, or at a kiosk when they check in.
- Answers ready for the clinician. Clinicians see what the patient said before the visit starts.
- Less workload at the front desk. Staff spend less time handing out forms and entering answers by hand.
- Key details at a glance. The care team sees what matters up front and decides who needs attention first.
The form becomes a natural conversation: patients answer by talking, in their own words. AI Doctor is an information and patient-assistance interface. It collects answers for the care team to review. It doesn't diagnose, triage, or give treatment advice.
Sample shortness of breath questionnaire questions
Typical questions, written out so you can see the level of detail. Every practice words its own form differently.
- How long have you been breathless?Duration
- Is your breathlessness getting better or worse?Duration
- What makes you breathless?Triggers
- Which activity makes you most breathless?Triggers
- How far can you walk on flat ground?Activity
- Can you climb two flights of stairs?Activity
- Do you cough or wheeze when breathless?Other symptoms
- Do you get chest pain when breathless?Other symptoms
- Have you had a heart attack or stroke?Health history
- Do you smoke, or did you ever?Health history
- What tests have you had for your breathing?Past care
- Which treatments have you tried, and did they help?Past care
These are examples to read, not a form to fill in.
Shortness of breath questionnaire: FAQ
What does a shortness of breath questionnaire ask?
The questions on this page follow the Woolcock Breathlessness Clinic questionnaire and cover six areas: duration, triggers, activity, other symptoms, health history, and past care.
Who fills in a shortness of breath questionnaire, and when?
On the Woolcock form, the patient fills it in before the first clinic visit. Patients also bring previous chest x-rays and contact details for other specialists.
Is it the same as an exertional dyspnea questionnaire?
Mostly. Exertional dyspnea means breathlessness with activity, and the Woolcock form also asks how breathlessness feels and what has been tried.
Does the form decide if breathlessness comes from the heart or lungs?
The form only collects the patient's answers. The practice's team reviews them and decides what to check next.
Is there a shortness of breath questionnaire template?
The Woolcock breathlessness clinic in Australia publishes its patient questionnaire as a PDF. The sample questions on this page show a typical set.
What happens after the form is completed?
The clinician reads the answers before the visit and asks for more detail where needed. Any tests are decided by the practice.
Does AI Doctor give medical advice?
No. It collects information for the care team. It doesn't diagnose, triage, or recommend treatment.
Can patient answers stay on our own servers?
Yes. RAVATAR offers on-prem deployment: the platform can run inside your own perimeter, so patient answers stay there. RAVATAR complies with GDPR and the EU AI Act.
Set up your AI Doctor in Genesis AI Avatar Studio
Genesis AI Avatar Studio is where you set up, test, and publish AI avatars for your website, mobile app, or Holobox. No coding or technical skills needed.
- 01Choose the AI Doctor avatar.
- 02Add your practice's FAQs and visit information.
- 03Talk to it, then publish it.
