Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Select an option below from 0 being "I never cough" to 5 being "I cough all the time": *

0

1

2

3

4

5

Select an option below from 0 being "I have no phlegm (mucus) in my chest at all" to 5 being "My chest is completely full of phlegm (mucus)": *

0

1

2

3

4

5

Select an option below from 0 being "My chest does not feel tight at all" to 5 being "My chest feels very tight": *

0

1

2

3

4

5

Select an option below from 0 being "When I walk up a hill or one flight of stairs I am not breathless" to 5 being "When I walk up a hill or one flight of stairs I am very breathless": *

0

1

2

3

4

5

Select an option below from 0 being "I am not limited doing any activities at home" to 5 being "I am very limited doing activities at home": *

0

1

2

3

4

5

Select an option below from 0 being "I am confident leaving my home despite my lung condition" to 5 being "I am not at all confident leaving my home because of my lung condition": *

0

1

2

3

4

5

Select an option below from 0 being "I sleep soundly" to 5 being "I don’t sleep soundly because of my lung condition": *

0

1

2

3

4

5

Select an option below from 0 being "I have lots of energy" to 5 being "I have no energy at all": *

0

1

2

3

4

5

Select one of the following: *

Grade 1: Not troubled by breathless except on strenuous exercise

Grade 2: Short of breath when hurrying on a level or when walking up a slight hill

Grade 3: Walks slower than most people on the level, stops after a mile or so, or stops after 15 minutes walking at own pace

Grade 4: Stops for breath after walking 100 yards, or after a few minutes on level ground

Grade 5: Too breathless to leave the house, or breathless when dressing/undressing