Respiratory Symptom Evaluation

For the following questions, please think about your experiences in the past 30 days

* Morning cough:

Morning cough with phlegm or mucus

Never (0 days out of the last 30 days)

Rarely (1-5 days)

Occasionally (6-15 days)

Most days (16-29 days)

Every day (all 30 days out of the last 30 days)

* Cough frequently:

Cough frequently throughout the day

Never (0 days out of the last 30 days)

Rarely (1-5 days)

Occasionally (6-15 days)

Most days (16-29 days)

Every day (all 30 days out of the last 30 days)

* Shortness of Breath:

My shortness of breath makes it difficult to do normal daily activities such as walking up a flight of stairs or carrying a heavy object

Never (0 days out of the last 30 days)

Rarely (1-5 days)

Occasionally (6-15 days)

Most days (16-29 days)

Every day (all 30 days out of the last 30 days)

* Easily winded:

Becoming easily winded during normal daily activities(e.g. doing laundry and carrying groceries)

Never (0 days out of the last 30 days)

Rarely (1-5 days)

Occasionally (6-15 days)

Most days (16-29 days)

Every day (all 30 days out of the last 30 days)

* Wheezing:

Wheezing or whistling in your chest at times when you are not exercising or doing other physically strenuous daily activities (e.g. while resting)

Never (0 days out of the last 30 days)

Rarely (1-5 days)

Occasionally (6-15 days)

Most days (16-29 days)

Every day (all 30 days out of the last 30 days)

Patient Support - Respiratory Symptom Evaluation