{"id":1354,"date":"2018-05-02T19:45:40","date_gmt":"2018-05-02T18:45:40","guid":{"rendered":"http:\/\/www.drpolding.scot.nhs.uk\/?page_id=1354"},"modified":"2019-02-09T10:41:08","modified_gmt":"2019-02-09T10:41:08","slug":"breathlessness-review-form","status":"publish","type":"page","link":"https:\/\/www.drpolding.scot.nhs.uk\/managing-your-health\/health-review-forms\/breathlessness-review-form\/","title":{"rendered":"Breathlessness Review Form"},"content":{"rendered":"<link rel='stylesheet' id='formidable-css' href='https:\/\/www.drpolding.scot.nhs.uk\/wp-content\/plugins\/formidable\/css\/formidableforms.css?ver=5121254' media='all' \/>\n<div class=\"frm_forms  with_frm_style frm_style_big_text\" id=\"frm_form_21_container\" >\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_hnlsj637\"  >\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">Breathlessness Review<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"21\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_21\" id=\"frm_hide_fields_21\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"hnlsj637\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_21\" name=\"frm_submit_entry_21\" value=\"c4b344490f\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/wp-json\/wp\/v2\/pages\/1354\" \/><div id=\"frm_field_477_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_half\">\r\n    <label for=\"field_xu1tj637\" class=\"frm_primary_label\">First Name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_xu1tj637\" name=\"item_meta[477]\" value=\"\"  data-reqmsg=\"First Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_478_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_half\">\r\n    <label for=\"field_xt7az637\" class=\"frm_primary_label\">Last Name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_xt7az637\" name=\"item_meta[478]\" value=\"\"  data-reqmsg=\"Last Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_479_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_ppbxb637\" class=\"frm_primary_label\">Email\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_ppbxb637\" name=\"item_meta[479]\" value=\"\"  data-reqmsg=\"Email cannot be blank.\" aria-required=\"true\" data-invmsg=\"Email is invalid\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_ppbxb637\"\/>\r\n    <div class=\"frm_description\" id=\"frm_desc_field_ppbxb637\">Enter Email<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_conf_479_container\" class=\"frm_form_field frm_none_container frm_conf_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_conf_ppbxb637\" class=\"frm_conf_label frm_primary_label\">Confirm Email\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_conf_ppbxb637\" name=\"item_meta[conf_479]\" value=\"\"  placeholder=\"Please confirm your email\" data-reqmsg=\"Confirm Email cannot be blank.\" aria-required=\"true\" data-confmsg=\"The entered values do not match\" data-invmsg=\"Email is invalid\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_conf_ppbxb637\"\/>\r\n    <div class=\"frm_description\" id=\"frm_desc_field_conf_ppbxb637\">Confirm Email<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_480_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_half\">\r\n    <label for=\"field_w1eya637\" class=\"frm_primary_label\">Date of birth\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_w1eya637\" name=\"item_meta[480]\" value=\"\"  data-frmmask=\"99\/99\/9999\" placeholder=\"DD\/MM\/YYYY\" data-reqmsg=\"Date of birth cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\" pattern=\"\\d\\d\\\/\\d\\d\\\/\\d\\d\\d\\d$\"   aria-describedby=\"frm_desc_field_w1eya637\"\/>\r\n    <div class=\"frm_description\" id=\"frm_desc_field_w1eya637\">Please use format day\/month\/year e.g. 12\/05\/1979<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_481_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_half\">\r\n    <label for=\"field_spq8l437\" class=\"frm_primary_label\">Phone Number\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_spq8l437\" name=\"item_meta[481]\" value=\"\"  data-reqmsg=\"Phone Number cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_482_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Your Breathlessness Review<\/h3>\r\n\r\n\r\n<div id=\"frm_field_483_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n    <label for=\"field_7t4cj\" class=\"frm_primary_label\">How do you rate your level of breathlessness?\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_radio\" id=\"frm_radio_483-482-0\"><label for=\"field_7t4cj-0\">\t\t<input type=\"radio\" name=\"item_meta[483]\" id=\"field_7t4cj-0\" value=\"I\u2019m not troubled by breathlessness\"\n\t\t   data-sectionid=\"482\" data-reqmsg=\"How do you rate your level of breathlessness? cannot be blank.\" data-invmsg=\"How do you rate your level of breathlessness? is invalid\" aria-invalid=\"false\"  \/> I\u2019m not troubled by breathlessness<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_483-482-1\"><label for=\"field_7t4cj-1\">\t\t<input type=\"radio\" name=\"item_meta[483]\" id=\"field_7t4cj-1\" value=\"I get breathless when I undertake vigorous exercise\"\n\t\t   data-sectionid=\"482\" data-reqmsg=\"How do you rate your level of breathlessness? cannot be blank.\" data-invmsg=\"How do you rate your level of breathlessness? is invalid\" aria-invalid=\"false\"  \/> I get breathless when I undertake vigorous exercise<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_483-482-2\"><label for=\"field_7t4cj-2\">\t\t<input type=\"radio\" name=\"item_meta[483]\" id=\"field_7t4cj-2\" value=\"I get short of breath when hurrying or walking up slopes\"\n\t\t   data-sectionid=\"482\" data-reqmsg=\"How do you rate your level of breathlessness? cannot be blank.\" data-invmsg=\"How do you rate your level of breathlessness? is invalid\" aria-invalid=\"false\"  \/> I get short of breath when hurrying or walking up slopes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_483-482-3\"><label for=\"field_7t4cj-3\">\t\t<input type=\"radio\" name=\"item_meta[483]\" id=\"field_7t4cj-3\" value=\"When walking I have to stop from time to time or walk slower due to breathlessness\"\n\t\t   data-sectionid=\"482\" data-reqmsg=\"How do you rate your level of breathlessness? cannot be blank.\" data-invmsg=\"How do you rate your level of breathlessness? is invalid\" aria-invalid=\"false\"  \/> When walking I have to stop from time to time or walk slower due to breathlessness<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_483-482-4\"><label for=\"field_7t4cj-4\">\t\t<input type=\"radio\" name=\"item_meta[483]\" id=\"field_7t4cj-4\" value=\"I have to stop for breath after a few minutes of walking a short distance on level ground\"\n\t\t   data-sectionid=\"482\" data-reqmsg=\"How do you rate your level of breathlessness? cannot be blank.\" data-invmsg=\"How do you rate your level of breathlessness? is invalid\" aria-invalid=\"false\"  \/> I have to stop for breath after a few minutes of walking a short distance on level ground<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_483-482-5\"><label for=\"field_7t4cj-5\">\t\t<input type=\"radio\" name=\"item_meta[483]\" id=\"field_7t4cj-5\" value=\"I\u2019m too breathless to leave the house and get breathless when getting dressed\"\n\t\t   data-sectionid=\"482\" data-reqmsg=\"How do you rate your level of breathlessness? cannot be blank.\" data-invmsg=\"How do you rate your level of breathlessness? is invalid\" aria-invalid=\"false\"  \/> I\u2019m too breathless to leave the house and get breathless when getting dressed<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_485_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Privacy Policy<\/h3>\r\n\r\n\r\n<div id=\"frm_field_486_container\" class=\"frm_form_field  frm_html_container form-field\">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 <a href=\"\/about-us\/practice-policies\/privacy-policy\/\" target=\"_blank\">Privacy Policy<\/a> to discover how we protect and manage your submitted data.<\/div>\n<div id=\"frm_field_487_container\" class=\"frm_form_field form-field  frm_required_field frm_inline_container vertical_radio\">\r\n    <label for=\"field_gbhp9\" class=\"frm_primary_label\"> \r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_487-485-0\"><label for=\"field_gbhp9-0\"><input type=\"checkbox\" name=\"item_meta[487][]\" id=\"field_gbhp9-0\" value=\"I consent to the practice collecting and storing my data from this form.\"  data-sectionid=\"485\" data-reqmsg=\"We need your consent to proceed. Please tick the box to consent.\" data-invmsg=\"  is invalid\" aria-invalid=\"false\"   aria-required=\"true\"  \/> I consent to the practice collecting and storing my data from this form.<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t<input name=\"frm_state\" type=\"hidden\" value=\"ytt8me3z\/ppVmsQc7n0lJ\/rUph6luvBT5xpCqatXa8Q=\" \/><div class=\"frm_submit\">\r\n\r\n<button class=\"frm_button_submit frm_final_submit\" type=\"submit\"   formnovalidate=\"formnovalidate\">Send<\/button>\r\n\r\n<\/div><\/div>\n<\/fieldset>\n<\/div>\n<\/form>\n<\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":6577921,"featured_media":0,"parent":1340,"menu_order":3,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"_coblocks_attr":"","_coblocks_dimensions":"","_coblocks_responsive_height":"","_coblocks_accordion_ie_support":"","_uag_custom_page_level_css":"","advgb_blocks_editor_width":"","advgb_blocks_columns_visual_guide":"","footnotes":"","_links_to":"","_links_to_target":""},"acf":[],"uagb_featured_image_src":{"full":false,"thumbnail":false,"medium":false,"medium_large":false,"large":false,"1536x1536":false,"2048x2048":false},"uagb_author_info":{"display_name":"Editor","author_link":"https:\/\/www.drpolding.scot.nhs.uk\/author\/gary-genpra\/"},"uagb_comment_info":0,"uagb_excerpt":null,"coauthors":[],"author_meta":{"author_link":"https:\/\/www.drpolding.scot.nhs.uk\/author\/gary-genpra\/","display_name":"Editor"},"relative_dates":{"created":"Posted 6 years ago","modified":"Updated 5 years ago"},"absolute_dates":{"created":"Posted on 2nd May 2018","modified":"Updated on 9th February 2019"},"absolute_dates_time":{"created":"Posted on 2nd May 2018 7:45 pm","modified":"Updated on 9th February 2019 10:41 am"},"featured_img_caption":"","featured_img":false,"series_order":"","publishpress_future_action":{"enabled":false,"date":"2024-05-19 20:51:25","action":"change-status","newStatus":"draft","terms":[],"taxonomy":""},"_links":{"self":[{"href":"https:\/\/www.drpolding.scot.nhs.uk\/wp-json\/wp\/v2\/pages\/1354"}],"collection":[{"href":"https:\/\/www.drpolding.scot.nhs.uk\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.drpolding.scot.nhs.uk\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.drpolding.scot.nhs.uk\/wp-json\/wp\/v2\/users\/6577921"}],"replies":[{"embeddable":true,"href":"https:\/\/www.drpolding.scot.nhs.uk\/wp-json\/wp\/v2\/comments?post=1354"}],"version-history":[{"count":0,"href":"https:\/\/www.drpolding.scot.nhs.uk\/wp-json\/wp\/v2\/pages\/1354\/revisions"}],"up":[{"embeddable":true,"href":"https:\/\/www.drpolding.scot.nhs.uk\/wp-json\/wp\/v2\/pages\/1340"}],"wp:attachment":[{"href":"https:\/\/www.drpolding.scot.nhs.uk\/wp-json\/wp\/v2\/media?parent=1354"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}