Health questionnaire

Attachment 5: Health Questionnaire

Form Approved:

OMB No. 0920-XXX

Exp. Date: ________

Health Questionnaire for study “Aerosol Generation by Cough”

Record Number:

Age:

Sex:

Height:

Weight:

Smoking History: ______Current ______Former ______Never

Average number of cigarettes per day _________

Age started __________ Age quit __________

Do you have any of the following conditions?				If YES, did a doctor tell you that you had this condition?			Do you take any medication for this problem?
Asthma	YES	NO		YES	NO		YES	NO
Emphysema	YES	NO		YES	NO		YES	NO
Frequent cough	YES	NO		YES	NO		YES	NO
Allergies	YES	NO		YES	NO		YES	NO
Chronic obstructive pulmonary disease (COPD)	YES	NO		YES	NO		YES	NO
Other Respiratory Illness (specify)	YES	NO		YES	NO		YES	NO

Public reporting burden of this collection of information is estimated to average 5 minutes per response. 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (XXXX-XXXX).