15 Respiratory

ID NUMBER:

FORM CODE: RSE VERSION: A 7/05/07

Contact Occasion

SEQ #

OMB#: 0925-XXXX

Exp. XX/XXXX

Public reporting burden for this collection of information is estimated to average 09 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-XXXX). Do not return the completed form to this address.

H

OMB#: 0925-XXXX

Exp. XX/XXXX

CHS/SOL Respiratory Questionnaire

ID NUMBER:

FORM CODE: RSE VERSION: A 7/05/07

Contact Occasion

SEQ #

Acrostic:

Administrative Information

0a. Completion Date: // 0b. Staff ID:

Month Day Year

Instructions: Mark the appropriate box for the response. Unless instructed, mark ONLY one response.

A. Respiratory Symptoms

The following questions are about respiratory or chest symptoms. If you are in doubt whether the answer is yes or no, answer no.

1. In the past 12 months, have you had a cough on most days or nights of the week during at least three months in a row? (“Most” means at least 4 days or nights per week)

No 0

Yes 1

2. Have you had a cough on getting up or first thing in the morning on most mornings (at least 4 per week) for at least three months in a row?

No 0

Yes 1

3. If “YES” to Question 1 OR Question 2, for how many years have you had this cough?

Years

4. In the past 12 months, have you brought up phlegm from your chest on most days or nights of the week during at least three months in a row? (“Most” means at least 4 days or nights per week)

No 0

Yes 1

5. Have you brought up phlegm on getting up or first thing in the morning on most mornings (at least 4 per week) for at least three months in a row?

No 0

Yes 1

6. If “YES” to Question 4 or Question 5, for how many years have you had trouble with this phlegm?

Years

7. Have you ever had wheezing or whistling in your chest?

No 0  GO TO QUESTION 18

Yes 1

8. About how old were you when you first had wheezing or whistling in your chest?

Age in years (Answer “1” if younger than 1 year)

9. Have you ever had an attack of wheezing or whistling in your chest that made you feel short of breath?

No 0  GO TO QUESTION 13

Yes 1

10. About how old were you when you had your first such attack?

Age in years (Answer “1” if younger than 1 year)

11. Have you had 2 or more such attacks?

No 0

Yes 1

Don’t know 9

12. Have you ever required medicine or treatment for such attacks?

No 0

Yes 1

Don’t know 9

13. In the last 12 months, have you had wheezing or whistling in your chest at any time?

No 0  GO TO QUESTION 18

Yes 1

In the last 12 months, does your chest ever sound wheezy or whistling…

14. When you have a cold? No 0

Yes 1

15. Occasionally apart from colds? No 0

Yes 1

16. More than once a week? No 0

Yes 1

17. Most days and nights? No 0

Yes 1

18. In the last 12 months, have you been awakened from sleep either by coughing (apart from a cough associated with a cold or chest infection) or by shortness of breath or a feeling of tightness in your chest?

No 0

Yes 1

19. When you are near animals (such as cats, dogs, or horses) or near feathers (including pillows, quilts or comforters) or in a dusty or moldy part of the house, do you ever:

No Yes

a. start to cough, wheeze, feel short of breath,

or feel a tightness in your chest? 0 1

b. get a runny or stuffy nose or start to sneeze,

or get itching or watering eyes? 0 1

20. When you are near trees, grass, or flowers, or when there is a lot of pollen in the air, do you ever:

No Yes

a. start to cough, wheeze, feel short of breath,

or feel a tightness in your chest? 0 1

b. get a runny or stuffy nose, start to sneeze,

or get itching or watering eyes? 0 1

21. Have you ever had allergen skin testing? No 0

Yes 1

22. Do you have chronic sinusitis? No 0

Yes 1

23. When you exercise or exert yourself or when the air is cold, do you ever start to cough, wheeze, feel short of breath, or feel tightness in your chest?

No 0

Yes 1

24. Are you troubled by shortness of breath when hurrying on level ground or walking up a slight hill?

No 0  GO TO QUESTION 29

Yes 1

25. Do you have to walk slower than people of your age on level ground because of shortness of breath? No 0

Yes 1

Does not apply 2

26. Do you ever have to stop for breath when walking at your own pace on level ground?

No 0

Yes 1

Does not apply 2

27. Do you ever have to stop for breath after walking about 100 yards (or after a few minutes) on level ground?

No 0

Yes 1

Does not apply 2

28. Are you too short of breath to leave the house or short of breath on dressing or undressing?

No 0

Yes 1

Does not apply 2

29. During the past 12 months, about how many days of work or school did you miss because of respiratory illnesses or symptoms?

None 0

1-5 1

6-15 2

16 or more 3

Not applicable—does 4  GO TO QUESTION 32

not go to work or school

30. During the past 12 months, have you had respiratory symptoms (cough, phlegm, wheeze, or shortness of breath) that changed on weekends, vacations, or other times when you were away from your current job? If more than one current job, consider the job you spend the most time doing.

No 0  GO TO QUESTION 32

Yes 1

Don’t know 2  GO TO QUESTION 32

Not applicable—do 3  GO TO QUESTION 32

not have a current job

that involves work out

of the home

31. Do your respiratory symptoms get better or worse when you are away from your current job?

Better 0

Worse 1

Don’t know 2

B. Respiratory Conditions

32. Have you ever had asthma? No 0  GO TO QUESTION 38

Yes 1

Don’t know 9  GO TO QUESTION 38

33. At about what age did it start?

Age in years (Answer “1” if younger than 1 year)

If age is known  GO TO QUESTION 34

33a. As a child; age not known

34. Was it diagnosed by a doctor or other health professional?

No 0

Yes 1

Don’t know 9

35. Do you still have it?

No 0

Yes 1  GO TO QUESTION 37

Don’t know 9

36. At what age did it stop?

Age in years (Answer “1” if younger than 1 year)

37. In the past 12 months, have you received medical treatment, taken medications or used an inhaler for asthma?

No 0

Yes 1

38. Have you ever had hay fever (allergy involving the nose and/or eyes)?

No 0  GO TO QUESTION 40

Yes 1

Don’t know 9  GO TO QUESTION 40

39. In the past 12 months, have you received medical treatment, taken medications or used a nasal spray for hay fever?

No 0

Yes 1

40. Has a doctor ever told you that you had pneumonia or bronchopneumonia?

No 0  GO TO QUESTION 42

Yes 1

Don’t know 9  GO TO QUESTION 42

41. At about what age did you first have pneumonia or bronchopneumonia?

Age in years (Answer “1” if younger than 1 year)

If age is known  GO TO QUESTION 42

41a. As a child; age not known

42. Has a doctor ever told you that you had chronic bronchitis?

No 0  GO TO QUESTION 44

Yes 1

Don’t know 9  GO TO QUESTION 44

43. At about what age did you first have chronic bronchitis?

Age in years (Answer “1” if younger than 1 year)

If age is known  GO TO QUESTION 44

43a. As a child; age not known

44. Has a doctor ever told you that you had COPD (chronic obstructive pulmonary disease) or emphysema?

No 0  GO TO QUESTION 47

Yes 1

Don’t know 9  GO TO QUESTION 47

45. At about what age did it start?

Age in years (Answer “1” if younger than 1 year)

46. In the past 12 months, have you received medical treatment, taken medications or used an inhaler for COPD or emphysema?

No 0

Yes 1

C. Family History Questions

The following questions refer to blood relatives. When asked about siblings, do not include half-brothers or half-sisters.

47. Has a doctor ever said that these relatives had an attack of asthma?

a. Mother No or Don’t know 0 Yes 1

b. Father No or Don’t know 0 Yes 1

c. Sibling(s) No or Don’t know 0 Yes 1

48. Has a doctor ever said that these relatives had chronic bronchitis, COPD, or emphysema?

a. Mother No or Don’t know 0 Yes 1

b. Father No or Don’t know 0 Yes 1

c. Sibling(s) No or Don’t know 0 Yes 1

49. Has a doctor ever said that these relatives had hay fever (allergy involving the nose and/or eyes)?

a. Mother No or Don’t know 0 Yes 1

b. Father No or Don’t know 0 Yes 1

c. Sibling(s) No or Don’t know 0 Yes 1

D. Tuberculosis Screening

50. Were you ever told that you had active tuberculosis or TB?

No 0  GO TO QUESTION 52

Yes 1

Refused 2

Don’t know 9

51. Were you ever prescribed any medicine to treat active tuberculosis or TB?

No 0

Yes 1

Refused 2

Don’t know 9

52. Have you ever been given a TB or tuberculosis skin test (e.g., PPD)?

No 0  GO TO QUESTION 55

Yes 1

Refused 2  GO TO QUESTION 55

Don’t know 9  GO TO QUESTION 55

53. Was it: Positive 1

Negative 2  GO TO QUESTION 55

Don’t know 9  GO TO QUESTION 55

54. Were you prescribed any medicine to keep you from getting sick with TB?

No 0

Yes 1

Don’t know 9

55. Have you ever had a shot (vaccination) to prevent TB called BCG?

No 0

Yes 1

Refused 2

Don’t know 9

E. Current Home Environment

56. During the last 12 months, has there been any flooding or water damage in your home?

No 0

Yes 1

57. During the last 12 months, have you noted any mold or mildew on any surface, other than food, inside your home?

No 0

Yes 1

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