ats kuesioner

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ATS-DLD-78-A || ADULT QUESTIONNAIRE - SELF COMPLETION|| (for those 13 years of age and older)|| Thank you for your willingness to participate. You were selected|| by a scientific sampling procedure, and your cooperation is very|| important to the success of this study.|| This is a questionnaire you are asked to fill out. Please answer|| the questions as frankly and accurately as possible. ALL INFORMATION|| OBTAINED IN THE STUDY WILL BE KEPT CONFIDENTIAL AND USED FOR MEDICAL|| RESEARCH ONLY. Your personal physician will be informed about the test|| results if you desire.

||-----------------------------------------------------------------------------|

IDENTIFICATION

IDENTIFICATION NUMBER: #####

NAME:_________________________ ________________________ ___(Last) (First) (MI)

STREET ______________________________________________________

CITY ____________________________ STATE ____ ZIP _______

PHONE NUMBER: ( ) ______-__________

INTERVIEWER: ###

DATE: ___________________MO DAY YR

==============================================================================

1. BIRTHDATE: _____ ____ ______Month Day Year

2. Place of Birth: _______________________________

3. Sex: 1. Male ____2. Female ____

4. What is your marital status? 1. Single ____2. Married ____3. Widowed ____4. Separated/Divorced ____


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5. Race: 1. White ____

2. Black ____3. Oriental ____4. Other ____

6. What is the highest grade completed in school? __________(For example: 12 years is completion of high school)

==============================================================================

SYMPTOMSThese questions pertain mainly to your chest. Please answer yes or noif possible. If a question does not appear to be applicable to you,check the does not apply space. If you are in doubt about whether youranswer is yes or no, record no.

COUGH

7A. Do you usually have a cough? 1. Yes ___ 2. No___

(Count a cough with first smoke or on first goingout-of-doors. Exclude clearing of throat.)[If no,skip to question 7C.]

B. Do you usually cough as much as 4 to 6 times a 1. Yes ___ 2. No___

day, 4 or more days out of the week?

C. Do you usually cough at all on getting up, or 1. Yes ___ 2. No___

first thing in the morning?

D. Do you usually cough at all during the rest 1. Yes ___ 2. No___

of the day or at night?

IF YES TO ANY OF THE ABOVE(7A,7B,7C, OR 7D), ANSWER THE FOLLOWING:IF NO TO ALL, CHECK DOES NOT APPLY AND SKIP TO 8A.

E. Do you usually cough like this on most days for 1. Yes ___ 2. No___

5 consecutive months or more during the year?8. Does not apply

__

F. For how many years have you had this cough?____________________

Number of years88. Does not apply

__

================================================================================

PHLEGM


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8A. Do you usually bring up phlegm from your chest? 1. Yes ___ 2. No___

(Count phlegm with the first smoke or on firstgoing out-of-doors. Exclude phlegm from thenose. Count swallowed phlegm)[If no, skip to 8C.]

B. Do you usually bring up phlegm like this as 1. Yes ___ 2. No___

much as twice a day, 4 or more days out of theweek?

C. Do you usually bring up phlegm at all on get- 1. Yes ___ 2. No___

ting up or first thing in the morning?

D. Do you usually bring up phlegm at all during 1. Yes ___ 2. No___

the rest of the day or at night?

IF YES TO ANY OF THE ABOVE (8A, B, C, OR D),ANSWER THE FOLLOWING:IF NO TO ALL, CHECK DOES NOT APPLY AND SKIP TO 9A.

E. Do you bring up phlegm like this on most days 1. Yes ___ 2. No___

for 3 consecutive months or more during theyear? 8. Does not apply

__

F. For how many years have you had trouble with____________________

phlegm? Number of years88. Does not apply

__

==============================================================================

EPISODES OF COUGH AND PHLEGM

9A. Have you had periods or episodes of (in- 1. Yes ___ 2. No___

creased*) cough and phelgm lasting for 3weeks or more each year?*(For individuals who usually have cough and/orphlegm)

IF YES TO 9A:

B. For how long have you had at least 1 such____________________

episode per year? Number of years88. Does not apply

__


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==============================================================================

WHEEZING

10A. Does your chest ever sound wheezy or whis-tling:

1. When you have a cold? 1. Yes ___ 2. No___

2. Occaisonally apart from colds? 1. Yes ___ 2. No___

3. Most days or nights? 1. Yes ___ 2. No___

IF YES TO 1, 2, OR 3 IN 10A:

B. For how many years has this been present?____________________

Number of years88. Does not apply

__

11A. Have you ever had an ATTACK of wheezing that 1. Yes ___ 2. No___

has made you feel short of breath?

IF YES TO 11A:

B. How old were you when you had your first _______ Age inyears

such attack? 88. Does not apply__

C. Have you had 2 or more such episodes? 1. Yes ___ 2. No___

8. Does not apply__

D. Have you ever required medicine or treatment 1. Yes ___ 2. No___

for the(se) attack(s)? 8. Does not apply__

==============================================================================

BREATHLESSNESS

12. If disabled from walking by any conditionother than heart or lung disease, pleasedescribe and proceed to Question 14A.

Nature ofcondition(s):__________________________________________________

13A. Are you troubled by shortness of breath when


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hurrying on the level or walking up a slight hill? 1. Yes ___ 2. No___

IF YES TO 13A:

B. Do you have to walk slower than people of your 1. Yes ___ 2. No___

age on level because of breathlessness? 8. Does not apply__

C. Do you ever have to stop for breath when walk- 1. Yes ___ 2. No___

ing at your own pace on the level? 8. Does not apply__

D. Do you ever have to stop for breath after walk 1. Yes ___ 2. No___

ing about 100 yards(or after a few minutes) on 8. Does not apply__

the level?

E. Are you too breathless to leave the house or 1. Yes ___ 2. No___

breathless on dressing or undressing? 8. Does not apply__

==============================================================================

CHEST COLDS AND CHEST ILLNESSES

14A. If you get a cold, does it usually go to your 1. Yes ___ 2. No___

chest? (Usually means more than 1/2 the time) 8. Don't getcolds__

15A. During the past 3 years, have you had any 1. Yes ___ 2. No___

chest illnesses that have kept you off work, in-doors at home, or in bed?

IF YES TO 15A:

B. Did you produce phlegm with any of these 1. Yes ___ 2. No___

chest illnesses? 8. Does not apply__

C. In the last 3 years, how many such illnesses, _____Number ofillnesses

with (increased) phlegm, did you have which _____No such illnesseslasted a week or more? _____Does not apply

==============================================================================

PAST ILLNESSES


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16. Did you have any lung trouble before the age 1. Yes ___ 2. No___

of 16?

17. Have you ever had any of the following:1A. Attacks of Bronchitis? 1. Yes ___ 2. No

___

IF YES TO 1A:B. Was it confirmed by a doctor? 1. Yes ___ 2. No

___8. Does not apply

__

C. At what age was your first attack? ______ Age inyears

88. Does not apply__

2A. Pneumonia (include bronchopneumonia)? 1. Yes ___ 2. No___



__

C. At what age did you first have it? ______ Age inyears


3A. Hayfever? 1. Yes ___ 2. No___



__

C. At what age did it start? ______ Age inyears


18A. Have you ever had chronic bronchitis? 1. Yes ___ 2. No___

IF YES TO 18A:B. Do you still have it? 1. Yes ___ 2. No


__


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C. Was it confirmed by a doctor? 1. Yes ___ 2. No___

8. Does not apply__

D. At what age did it start? ______ Age inyears


19A. Have you ever had emphysema? 1. Yes ___ 2. No___



__

C. Was it confirmed by a doctor? 1. Yes ___ 2. No


__



20A. Have you ever had asthma? 1. Yes ___ 2. No___



__

C. Was it confirmed by a doctor? 1. Yes ___ 2. No___

8. Does not apply__


88. Does not apply

__

E. If you no longer have it, at what age did it ______ Age stoppedstop? 88. Does not apply

__

21. Have you ever had:


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A. Any other chest illnesses? 1. Yes ___ 2. No___

If yes, please specify____________________________________________

B. Any chest operations? 1. Yes ___ 2. No___


C. Any chest injuries? 1. Yes ___ 2. No___


22A. Has doctor ever told you that you had heart 1. Yes ___ 2. No___

trouble?

IF YES to 22A:

B. Have you ever had treatment for heart trouble 1. Yes ___ 2. No___

in the past 10 years? 8. Does not apply__

23A. Has a doctor ever told you that you have high 1. Yes ___ 2. No___

blood pressure?

IF YES to 23A:

B. Have you had any treatment for high blood 1. Yes ___ 2. No___

pressure (hypertension) in the past 10 years? 8. Does not apply__

==============================================================================

OCCUPATIONAL HISTORY

24A. Have you ever worked full time (30 hours per 1. Yes ___ 2. No___

week or more) for 6 months or more?

IF YES to 24A:

B. Have you ever worked for a year or more in 1. Yes ___ 2. No___

any dusty job? 8. Does not apply__

Specify job/industry: _________________________ Total years worked__

Was dust exposure 1. Mild ___ 2. Moderate ___ 3. Severe ___ ?


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C. Have you ever been exposed to gas or chemical 1. Yes ___ 2. No___

fumes in your work? 8. Does not apply__

Specify job/industry: _________________________ Total years worked__

Was dust exposure 1. Mild ___ 2. Moderate ___ 3. Severe ___ ?

D. What has been your usual occupation or job -- the one you haveworked at the longest?

1. Job-occupation:__________________________________________________

2. Number of years employed in thisoccupation:______________________

3. Position-job title:______________________________________________

4. Business, field, or industry:____________________________________

==============================================================================

TOBACCO SMOKING

25A. Have you ever smoked cigarettes? (NO means 1. Yes ___ 2. No___

less than 20 packs of cigarettes or 12 oz. oftobacco in a lifetime or less than 1 cigarette aday for 1 year.

IF YES to 25A:

B. Do you now smoke cigarettes (as of 1 month 1. Yes ___ 2. No___

ago)? 8. Does not apply__

C. How old were you when you first started reg- ____ Age inYears

cigarette smoking? 88.Does not apply__

D. If you have stopped smoking cigarettes com- ____ Agestopped

pletely, how old were you when you stopped? Check if

still smoking___

88.Does not apply__

E. How many cigarettes do you smoke per day now? ___ Cigarettes/day88.Does not apply

__

F. On the average of the entire time you smoked, ___ Cigarettes/day


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how many cigarettes did you smoke per day? 88.Does not apply__

G. Do or did you inhale the cigarette smoke? 1. Does not apply__

2. Not at all______

3. Slightly________

4. Moderately______

5. Deeply__________

26A. Have you ever smoked a pipe regularly? 1. Yes ___ 2. No___

(YES means more than 12 oz tobacco in alifetime.)

IF YES to 26A:

B1. How old were you when you started to ____ Agesmoke a pipe regularly?

2. If you have stopped smoking a pipe com- ____ Agestopped

pletely, how old were you when you stopped? Check if stillsmoking pipe

____88.Does not apply

__

C. On the average over the entire time you ____ oz per week (astan-

smoked a pipe, how much pipe tobacco did dard pouch of tobaccocon-

you smoke per week ? tains 1 1/2 oz)88.Does not apply

__

D. How much pipe tobacco are you smoking now? ___ oz perweek

88. Not currently smoking a pipe___

E. Do or did you inhale the pipe smoke? 1. Never smoked____

2. Not at all______

3. Slightly________

4. Moderately______

5. Deeply__________


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27A. Have you ever smoked cigars regularly? 1. Yes ___ 2. No___

(Yes means more than 1 cigar a week for ayear).

IF YES to 27A:

B1. How old were you when you started smok- ____ Ageing cigars regularly?

2. If you have stopped smoking cigars com- ____ Agestopped

pletely, how old were you when you stopped? Check if stillsmoking

cigars___88.Does not apply

__

C. On the average over the entire time you ___ Cigars perweek

smoked cigars, how many cigars did you smoke 88.Does not apply__

per week ?

D. How many cigars are you smoking per week ___ Cigars perweek

now? 88. Check if not smoking cigars currently__

E. Do or did you inhale the cigar smoke? 1. Never smoked____

2. Not at all______

3. Slightly________

4. Moderately______

5. Deeply__________

==============================================================================

FAMILY HISTORY

28. Were either of your natural parents ever told by a doctor that theyhad a chronic lung condition such as:

FATHER MOTHER

1. YES 2. NO 3. DON'T 1. YES 2. NO 3. DON'TKNOW KNOW

A. Chronicbrochitis? _____ _____ _______ _____ _____ _______


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B. Emphysema? _____ _____ _______ _____ _____ _______

C. Asthma? _____ _____ _______ _____ _____ _______

D. Lung cancer? _____ _____ _______ _____ _____ _______

E. Other chestconditions? _____ _____ _______ _____ _____ _______

29A. Is parent currently alive?_____ _____ _______ _____ _____ _______

B. Please Specify:

_____ Age if living _____ Age if living

_____ Age at death _____ Age at death

8. Don't know _____ 8. Don't know _____

C. Please specify cause of death.________________________________ _________________________

Initial Questionnaire of the NIOSH

Occupational Asthma Identification Project

ID #: INS - AZ - ________________

Location: ___________________________

Date: ____/____/________


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**** General Tips before You Start ****

This questionnaire will ask you mainly about your health.

Read the whole question before making an answer.

Try to answer all questions unless you are told to skip them.

If you cannot decide whether to answer YES or NO, leave the question blank.

If there are several responses, select the one which best describes your

situation or symptoms, unless you are told to choose multiple answers.

IDENTIFICATION

1) NAME: _________________ _______________________ ___________

(Last) (First) (Middle Initial)

2) SOCIAL SECURITY #: _________ _____ _________

3) BIRTH DATE: _____/______/_____

(Month/Day/Year)

4) CURRENT ADDRESS: ____________________________________________

(Number, Street, or Rural Route)

____________________________________________


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____________________________________________

(City or Town, State, Zip Code)

5) HOME PHONE: (_________) _________ - _________________

6) SEX

1. MALE

2. FEMALE

7) RACE 7a) Are you of hispanic origin?

0. White 1. NO

1. Black 2. YES

2. Asian/Pac.

3. Am Ind/Eskimo

4. other

8) STANDING HEIGHT 9) WEIGHT

__________(inches) ________(lbs)

10) WHAT WAS THE HIGHEST GRADE OF SCHOOL YOU COMPLETED?

__________(years)

(Mark 12 if you have a high school diploma,

13 to 15 if you also have technical or associate training,

16 for a college degree, etc.)

11) This may be the last time we see you, but we would like to be


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able to keep you up to date on the results of the study. If you

move, is there someone who would know your new address? (For

example: parents, child, friend)

NAME: ___________________________ RELATIONSHIP: _________________

ADDRESS: ____________________________________________

(Number, Street, or Rural Route)

____________________________________________

(City or Town, State, Zip Code)

PHONE NUMBER: (_________) _________ - _________________


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ABOUT YOUR HEALTH

1. Have you ever had asthma?

1. NO

2. YES

2. Have you ever had an asthmatic attack?

1. NO

2. YES

IF YOU ANSWERED NO TO BOTH QUESTIONS 1 AND 2, SKIP TO QUESTION NUMBER 3

IF YOU ANSWERED "YES" TO EITHER OF THE ABOVE, PLEASE ANSWER QUESTIONS

2a, 2b and 2c.

2a) About what age did the asthma start?

__________ age in years or ____ don't know

2b) Was asthma confirmed by a doctor?

1. NO

2. YES


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2c) Do you still have asthma?

1. NO: How old were you when it stopped?

__________ age in years

2. YES: Do you now take any pills, capsules, or liquids,

including non-prescription medications for

asthma?

1. NO

2. YES (List the names: _________________

_________________________________)

3. Does your chest ever sound wheezing or whistling?

1. NO

2. YES: If "YES",

3a) Do you get this only when you have a cold?

1. NO

2. YES

occasionally apart from cold?

1. NO

2. YES


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most days or nights each week?

1. NO

2. YES

3b) Does the wheezing always clear after you cough?

1. NO

2. YES

4. Have you ever had attacks of shortness of breath with wheezing

or whistling?

1. NO

2. YES: If "YES", was your breathing absolutely normal between

attacks?

1. NO

2. YES

5. During the past 12 months, have you had an attack of shortness

of breath or coughing that came on when you were just lying in

bed or not doing any special effort?

1. NO

2. YES

6. During the past 12 months, has your chest ever felt tight for


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longer than a minute?

1. NO

2. YES

7. During the past 12 months, have you had an attack of shortness

of breath or coughing that came on shortly after you stopped

exercising?

1. NO

2. YES

IF YOU ANSWERED NO TO ALL THE QUESTIONS FROM 3 TO 7, THEN SKIP TO

QUESTION 19.

IF YOU ANSWERED "YES" TO ANY OF THE QUESTIONS FROM 3 TO 7, PLEASE

ANSWER ALL THE FOLLOWING QUESTIONS.

8. Which of the following best describes your breathing?

1. I never or only rarely get trouble with my breathing.

2. I get repeated trouble with my breathing, but it always

gets completely better.

3. My breathing is never quite right.

9. What have been the most troublesome chest symptom or symptoms?


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1. wheezing or whistling

2. attacks of shortness of breath

3. chest tightness

4. attacks of cough

5. other (Specify: _____________________)

Please answer the following questions about your most troublesome

chest symptom(s):

10. About how often have you had these symptoms?

1. Only once

2. Only a few days ever

3. A few days each year

4. A few days each month

5. A few days each week

6. Usually at least once each day or night

11. About what age did the symptoms first start?

___________ age in years

12. About what age did they last occur?

___________ age in years or ____ I still get them.

13. During the years that you had the chest symptoms, have you ever

had a break in your symptoms for as long as a year or more?


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1. NO

2. YES: IF "YES",

13a) Did you always take breathing medications during

the breaks in your symptoms?

1. NO

2. YES

13b) Since your last break, how long have you had the

symptoms?

_____________ years

14. Are/were your symptoms worse during a particular season of the

year?

1. NO, about the same in all seasons

2. YES: IF "YES", which is/was the worst season?

1. Winter

2. Spring

3. Summer

4. Fall

15. Are/were your symptoms worse at any particular time of day or night?:


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1. NO, not worse at any particular time of day or night

2. YES: IF "YES", when are/were they worse?

1. When you first wake up?

2. While at work?

3. After leaving work?

4. While lying in bed?

16. When you are off work on weekend or vacation, do/did your symptoms get:

1. no change.

2. better.

3. worse.

17. After you have returned to work from leave or vacation, do/did

your symptoms get:

1. no change.

2. better.

3. worse.

18. Regarding the most troublesome chest symptoms mentioned above,

are/were they brought on by, or made worse by (choose all that

apply):

Contact with animals/pets?

1. NO

2. YES


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Heavy exercise?

1. NO

2. YES

Plants or pollens

1. NO

2. YES

Exposure to insects at work?

1. NO

2. YES

Dusts, gases, or fumes at work?

1. NO

2. YES

Dusts or fumes in the home?

1. NO

2. YES

Exposure to tobacco smoke?


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1. NO

2. YES

19. Do you have any nerve, muscle, or bone problem or heart trouble

that makes walking quite difficult for you?

1. NO

2. YES (please specify: ____________________________

____________________________)

20. Are you troubled by shortness of breath when hurrying on level

ground or walking up a slight hill?

1. NO: IF NO, SKIP TO QUESTION 21.

2. YES: IF "YES",

20a) Do you get short of breath walking with other

people of your own age on level ground?

1. NO: IF NO, SKIP TO QUESTION 21.

2. YES: IF "YES",

20a1) Do you have to stop for breath when walking

at your own pace on level ground?

1. NO

2. YES


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21. Do you usually cough on getting up, or first thing in the

morning in the winter?

(Count a cough with first smoke or on first going out-of-doors.

Exclude clearing throat or a single cough.)

[usually] means 4 or more days per week

1. NO

2. YES

22. Do you usually cough during the day - or at night - in the

winter?

(Ignore an occasional cough.)


1. NO

2. YES

IF YOU ANSWERED NO TO BOTH QUESTIONS 21 AND 22, SKIP TO QUESTION 23


22a and 22b.


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22a) Do you cough like this on most days - or nights - for as

much as three months during the year?

1. NO

2. YES

22b) How many years have you coughed like this?

_________ YEARS

23. Do you usually bring up any phlegm from your chest on getting

up, or first thing in the morning in the winter?

(Count phlegm with first smoke or on first going out of doors.

Exclude phlegm from the nose. Count swallowed phlegm.)


1. NO

2. YES

24. Do you usually bring up any phlegm from your chest during the

day - or at night - in the winter?

(If twice or more in a day, mark YES.)


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1. NO

2. YES

IF YOU ANSWERED NO TO BOTH QUESTIONS 23 AND 24, SKIP TO QUESTION 25.


24a and 24b.

24a) Do you bring up phlegm like this on most days - or nights -

for as much as three months during the year?

1. NO

2. YES

24b) How many years have you brought up phlegm like this?

_________ YEARS

25. Do you usually have a stuffy nose, or drainage at the back of


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your nose?

1. NO

2. YES

26. During the past 12 months, have you had two or more episodes of

blocked, itchy, or runny nose?

1. NO

2. YES

IF YOU ANSWERED NO TO BOTH QUESTIONS 25 AND 26, SKIP TO QUESTION 27


26a thru 26e.

26a) Do you usually have these nose symptoms at any particular

time of year?


2. YES: IF "YES", which is the worst season?

1. Winter

2. Spring

3. Summer

4. Fall

26b) When you have nose symptoms, do you usually have fever,

headache, or general body ache?


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1. NO

2. YES

26c) Were these nose symptoms mainly due to one of the

following?

1. cold or flu

2. hay fever

3. other allergies

4. something else (specify:____________________)

26d) At what age did you first notice the nose symptoms?

_______ years in age

26e) Do the nose symptoms seem better or worse when you were

away from work, on vacation, sick leave, or a lay-off?

1. NO, neither better nor worse away from work

2. YES, better away from work

3. YES, worse away from work

27. During the past 12 months, have your eyes been red, itchy, or

watery more than twice?

1. NO

2. YES


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IF YOU ANSWERED NO TO QUESTION 27, SKIP TO QUESTION 28.

IF YOU ANSWERED "YES", PLEASE ANSWER QUESTIONS 27a thru 27f.

27a) Over the past year, about how often have you noticed this?

1. less than 1 - 2 days altogether

2. less than 7 days

3. less than 30 days

4. more than 30 days

27b) Do you usually have these eye symptoms at any particular

time of year?


2. YES: IF "YES", which is the worst season?

1. Winter

2. Spring

3. Summer

4. Fall

27c) When you have eye symptoms, do you usually have fever,

headache, or general body ache?

1. NO

2. YES

27d) Were these eye symptoms mainly due to one of the following?


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1. contact lenses

2. cold or flu

3. hay fever

4. other allergies

5. something else (specify:______________)

27e) At what age did you first notice the eye symptoms?


27f) Did/does the eye symptom seem better or worse when you were

away from work, on vacation, sick leave, or a lay-off?




28. During the last 12 months, have you had a skin rash, dermatitis,

hives, or eczema?

[ Mark NO if your skin looks normal or is only dry. ]

1. NO

2. YES


IF YOU ANSWERED "YES", PLEASE ANSWER QUESTIONS 28a thru 28d.


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28a) What parts of your body were affected? (Check ( ) all that

apply)

AFFECTED BODY PART

Scalp ( )

Trunk ( )

Face or neck ( )

Groin or private part ( )

Hands or arms ( )

Feet or legs ( )

Other (Specify:_____________________________)

28b) Did any of the following substances cause rashes on your

skin? (Check ( ) all that apply)

Jewelry ( )


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Tapes, glues ( )

Clothing, gloves, shoes,

undergarments ( )

Cosmetics, perfume,

deodorant, after shave ( )

Hairdyes/colorings ( )

Soaps, detergents ( )

Skin medicine (ointment,

lotion, etc.) ( )

Poison ivy/oak ( )

Oils, greases ( )

Solvents ( )

Chemicals ( )

Others (Specify: _________________________________)

28c) At what age did you first notice these skin changes?



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28d) Did/does your skin seem better or worse when you were away

from work, on vacation, sick leave, or a lay-off?




29. Have you ever smoked cigarettes regularly?

1. NO

2. YES


IF YOU ANSWERED "YES" TO QUESTION 29, PLEASE ANSWER QUESTIONS 29a

thru 29d.

29a) How old were you when you first started smoking cigarettes

regularly?

__________ YEARS OLD (AGE)

29b) Do you still smoke cigarettes?

1. NO: IF "NO", how old were you when you last gave up smoking?


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__________ YEARS OLD (AGE)

2. YES

29c) During the years that you smoked, did you ever quit for 6

months or more?

1. NO

2. YES: IF "YES", how long did you quit for altogether?

__________ YEARS

29d) Over the years that you smoked, on the average

approximately how many cigarettes per day did you smoke?

__________ Cigarettes per day.

30. Do you now smoke a pipe or cigar?

1. NO

2. YES

31. Since childhood, have you ever had

(Mark an X in appropriate area)


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Yes, in Yes, in No Unknown

the past the present

Hay fever?

Emphysema?

Tuberculosis?

Bronchitis?

Pneumonia?

Any Allergies to:

Foods?

Metals?

Chemicals?

Medicines?

Dusts?

Animals?

Others? (Specify:

________________________)


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32. Have you seen a doctor for any problem in the past year?

1. NO

2. YES: (Please specify):____________________________________________

__________________________________________________________________

33. Do you take any medications, including non-prescription

medicine, aside from vitamins?

1. NO

2. YES: (Please specify):____________________________________________

__________________________________________________________________

ABOUT YOUR FAMILY

INDICATE ANY BLOOD RELATIVES WHO EVER HAD ANY OF THE FOLLOWING:

(Do not include relatives by marriage.)

If family history is completely unknown (subject is adopted, etc.),

mark this space ( ) and leave the following blank.

(Mark an X in appropriate area)


38/39

PROBLEM PARENTS GRAND BROTHER/ CHILDREN UNKNOWN

PARENTS SISTER IN FAMILY

ANY KIND OF

ALLERGIES?

Hay Fever

Eczema

Asthma

Sinus Problem

Other

Allergies

ANY LUNG DISEASES

SUCH AS:

Emphysema?

Tuberculosis?

Chronic

Bronchitis?


39/39

Pneumonia?

Other lung

trouble?

ats kuesioner

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