Pulmonary Health Questionnaire

Attachment 3 Pulmonary Health Questionnaire



Form Approved

OMB no. 0920-0494

Exp. Date xx/xx/20xx

Exposure to Aerosolized Brevetoxin During Red Tide Events

Pulmonary Health Questionnaire

National Center for Environmental Health

Centers for Disease Control and Prevention

Florida Department of Health

University of Miami School of Medicine

Name: _________________ _________________ ___________

(Last) (First) (Middle Initial)

Birth Date : _____/_____

mm / yyyy

Current Address:

____________________________________________

(Number, Street, or Rural Route)

____________________________________________

____________________________________________

(City or Town, State, Zip Code)

Home Phone: (_________) _________ ‑ _________________

Public reporting burden for this collection of information is estimated to vary from 4 to 6 minutes per response, with an average response of 5 minutes, 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: CDC/ATSDR Reports Clearance Officer; Paperwork Reduction Project (0920-0494); M.S. D-24; 1600 Clifton Road NE, Atlanta, Ga. 30333

1. INTERVIEWER ______________________________

2. DATE OF INTERVIEW ____/____/____

mm /dd / yyyy

3. LOCATION ______________________________

STREET ADDRESS

______________________________

NAME OF BEACH

______________________________

CITY

______________________________

STATE, ZIP

4. SEX

1. FEMALE

2. MALE

First, I would like to ask a few questions about yourself.

5. What is your race? 1. AMERICAN INDIAN, ALASKA NATIVE

2. ASIAN

3. BLACK OR AFRICAN AMERICAN

4. NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

5. WHITE

88. DON’T KNOW

99. REFUSED

6. Are you of Hispanic origin? 1. NO

2. YES

88. DON’T KNOW

99. REFUSED

7. How many years of school have you completed?

_____ Number of years

88. DON’T KNOW

99. REFUSED

Now, I have a few questions about your heath.

8. Have you ever had asthma? 1. NO

2. YES

88. DON’T KNOW

99. REFUSED

9. Have you ever had an asthma attack? 1. NO

2. YES

88. DON’T KNOW

99. REFUSED

IF NO TO BOTH QUESTIONS 8 AND 9, SKIP TO QUESTION 10.

9a. At about what age did the asthma start? _______ AGE (YEARS)

77. NA

88. DON’T KNOW

99. REFUSED

9b. Was asthma confirmed by a doctor? 1. NO

2. YES

77. NA

88. DON’T KNOW

99. REFUSED

9c. Do you still have asthma? 1. NO (GO TO QUESTION 9c1)

2. YES (GO TO QUESTION 9c2)

77. NA

88. DON’T KNOW

99. REFUSED

9c1. How old were you when it stopped?

______ AGE (YEARS)

77. NA

88. DON’T KNOW

99. REFUSED

9c2. Do you now take any medicines, including non-prescription medicines, for asthma? 1. NO

2. YES

SPECIFY ____________________

____________________ ____________________

____________________

77. NA

88. DON’T KNOW

99. REFUSED

10. Have you ever done any pulmonary function tests? By pulmonary function tests, I mean spirometry, peak flow, etc.

1. NO

2. YES

77. NA

88. DON’T KNOW

99. REFUSED

Now, I would like to ask you about a series of symptoms, how often you may have had these symptoms, and whether or not they change.

Symptom	11. Shortness of breath with wheezing or whistling.	12. Shortness of breath or coughing that came on when you were just lying in bed or not doing any special effort.	13. Tightness in the chest that lasts for more than 1 minute.	14. Do you usually have a stuffy nose, or drainage at the back of your nose?
Have you experienced the symptom?	1. NO 2. YES	1. NO 2. YES	1. NO 2. YES	1. NO 2. YES
When did your symptoms first occur?	____/____/____ (DATE) mm dd yyyy 77. NA 88. DON’T KNOW 99. REFUSED	____/____/____ (DATE) mm dd yyyy 77. NA 88. DON’T KNOW 99. REFUSED	____/____/____ (DATE) mm dd yyyy 77. NA 88. DON’T KNOW 99. REFUSED	____/____/____ (DATE) mm dd yyyy 77. NA 88. DON’T KNOW 99. REFUSED
When was the last time you had these symptoms?	____/____/____ (DATE) mm dd yyyy 77. NA 88. DON’T KNOW 99. REFUSED	____/____/____ (DATE) mm dd yyyy 77. NA 88. DON’T KNOW 99. REFUSED	____/____/____ (DATE) mm dd yyyy 77. NA 88. DON’T KNOW 99. REFUSED	____/____/____ (DATE) mm dd yyyy 77. NA 88. DON’T KNOW 99. REFUSED
About how often do you have 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 77. NA 88. DON’T KNOW 99. REFUSED	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 77. NA 88. DON’T KNOW 99. REFUSED	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 77. NA 88. DON’T KNOW 99. REFUSED	1. ONLY ONCE 2. ONLY A FEW TIMES EVER 3. A FEW TIMES EACH YEAR 77. NA 88. DON’T KNOW 99. REFUSED
	Shortness of breath with wheezing or whistling. Continued	Shortness of breath or coughing that came on when you were just lying in bed or not doing any special effort. Continued	Tightness in the chest that lasts for more than 1 minute. Continued	Do you usually have a stuffy nose, or drainage at the back of your nose? Continued
Are/were your symptoms worse during a particular season?	1. NO, ABOUT THE SAME IN ALL SEASONS 2. WORSE IN SPRING 3. WORSE IN SUMMER 4. WORSE IN FALL 5. WORSE IN WINTER 77. NA 88. DON’T KNOW 99. REFUSED	1. NO, ABOUT THE SAME IN ALL SEASONS 2. WORSE IN SPRING 3. WORSE IN SUMMER 4. WORSE IN FALL 5. WORSE IN WINTER 77. NA 88. DON’T KNOW 99. REFUSED	1. NO, ABOUT THE SAME IN ALL SEASONS 2. WORSE IN SPRING 3. WORSE IN SUMMER 4. WORSE IN FALL 5. WORSE IN WINTER 77. NA 88. DON’T KNOW 99. REFUSED	1. NO, ABOUT THE SAME IN ALL SEASONS 2. WORSE IN SPRING 3. WORSE IN SUMMER 4. WORSE IN FALL 5. WORSE IN WINTER 77. NA 88. DON’T KNOW 99. REFUSED
Are/were your symptoms worse during a particular time or day or night?	1. NO, NOT WORSE AT ANY SPECIFIC TIME OF DAY OR NIGHT 2. WORSE WHEN I FIRST WAKE UP 3. WORSE WHILE AT WORK 4. WORSE AFTER LEAVING WORK 5. WORSE WHILE LYING IN BED 77. NA 88. DON’T KNOW 99. REFUSED	1. NO, NOT WORSE AT ANY SPECIFIC TIME OF DAY OR NIGHT 2. WORSE WHEN I FIRST WAKE UP 3. WORSE WHILE AT WORK 4. WORSE AFTER LEAVING WORK 5. WORSE WHILE LYING IN BED 77. NA 88. DON’T KNOW 99. REFUSED	1. NO, NOT WORSE AT ANY SPECIFIC TIME OF DAY OR NIGHT 2. WORSE WHEN I FIRST WAKE UP 3. WORSE WHILE AT WORK 4. WORSE AFTER LEAVING WORK 5. WORSE WHILE LYING IN BED 77. NA 88. DON’T KNOW 99. REFUSED	1. NO, NOT WORSE AT ANY SPECIFIC TIME OF DAY OR NIGHT 2. WORSE WHEN I FIRST WAKE UP 3. WORSE WHILE AT WORK 4. WORSE AFTER LEAVING WORK 5. WORSE WHILE LYING IN BED 77. NA 88. DON’T KNOW 99. REFUSED
Do/did your symptoms get better when you are/were off or work on the weekend or vacation?	1. NO 2. YES 77. NA 88. DON’T KNOW 99. REFUSED	1. NO 2. YES 77. NA 88. DON’T KNOW 99. REFUSED	1. NO 2. YES 77. NA 88. DON’T KNOW 99. REFUSED	1. NO 2. YES 77. NA 88. DON’T KNOW 99. REFUSED

Now, I have a few questions about cigarette smoking.

15. Have you ever smoked more than 100 cigarettes during your life?

1. NO (GO TO QUESTION 16)

2. YES

88. DON’T KNOW

99. REFUSED

15a. During the time you smoked, how many packs of cigarettes did you smoke each day?

1. <2 PACK

2. 1 PACK

3. 1 2 PACKS

4. >1 2 PACKS

77. NA

88. DON’T KNOW

99. REFUSED

15b. For how many years did you smoke? _____ YEARS

77. NA

88. DON’T KNOW

99. REFUSED

15c. Do you smoke now? 1. NO (GO TO QUESTION 15c1)

2. YES (GO TO QUESTION 15d)

77. NA

88. DON’T KNOW

99. REFUSED

15c1. About how many years ago did you quit?

____________ YEARS

77. NA

88. DON’T KNOW

99. REFUSED

GO TO QUESTION 16

15d. Did you smoke in the last month? 1. NO

2. YES

77. NA

88. DON’T KNOW

99. REFUSED

15e. Do you smoke some days or every day?

1. SOME DAYS

2. EVERY DAY

77. NA

88. DON’T KNOW

99. REFUSED

15f. About how many cigarettes do you smoke each day?

__________ NUMBER OF CIGARETTES

77. NA

88. DON’T KNOW

99. REFUSED

Now, I just have a few more questions about other illnesses that may affect your lungs.

Have you ever had? OR Do you now have?

Hay fever 16a 1. NO 16b 1. NO

2. YES 2. YES

88. DON’T KNOW 88. DON’T KNOW

99. REFUSED 99. REFUSED

Allergies 17a 1. NO 17b 1. NO

2. YES 2. YES

Specify Specify

________________ _______________

________________ _______________

________________ _______________

88. DON’T KNOW 88. DON’T KNOW

99. REFUSED 99. REFUSED

Emphsema 18a 1. NO 18b 1. NO

2. YES 2. YES

88. DON’T KNOW 88. DON’T KNOW

99. REFUSED 99. REFUSED

Tuberculosis 19a 1. NO 19b 1. NO

2. YES 2. YES

88. DON’T KNOW 88. DON’T KNOW

99. REFUSED 99. REFUSED

Bronchitis 20a 1. NO 20b 1. NO

2. YES 2. YES

88. DON’T KNOW 88. DON’T KNOW

99. REFUSED 99. REFUSED

Sinus problems 21a 1. NO 21b 1. NO

2. YES 2. YES

88. DON’T KNOW 88. DON’T KNOW

99. REFUSED 99. REFUSED

Other 22a. 1. NO 22b. 1. NO

2. YES 2. YES

Specify Specify

_____________________ _____________________

88. DON’T KNOW 88. DON’T KNOW

99. REFUSED 99. REFUSED

Now, just a couple of questions about your general health:

23. In the past year, did you have to go to the hospital because you had breathing problems or because there was any other problem with your chest or lungs (including trouble catching your breath, wheezing, etc.)? 1. NO (end interview)

2. Yes (go to question 23a)

77. NA

88…DON’T KNOW

99. REFUSED

For each of the times you went to the hospital, can you tell me why you went and when?

23a. Why did you go to the hospital (FIRST TIME)?

1. ASTHMA ATTACK

2. TROUBLE BREATHING

3. CHEST TIGHTNESS

4. WHEEZING

5. HEART ATTACK

6. OTHER

Specify ______________________

_____________________________

_____________________________

77. NA

88. DON’T KNOW

99. REFUSED

23a1. When did you go to the hospital (FIRST TIME)?

______/______

mm yyyy

77. NA

88. DON’T KNOW

99. REFUSED

23b. Why did you go to the hospital (SECOND TIME)?

1. ASTHMA ATTACK

2. TROUBLE BREATHING

3. CHEST TIGHTNESS

4. WHEEZING

5. HEART ATTACK

6. OTHER

Specify ______________________

_____________________________

_____________________________

77. NA

88. DON’T KNOW

99. REFUSED

23b1. When did you go to the hospital (SECOND TIME)?

______/______

mm yyyy

77. NA

88. DON’T KNOW

99. REFUSED

23c. Why did you go to the hospital (THIRD TIME)?

1. ASTHMA ATTACK

2. TROUBLE BREATHING

3. CHEST TIGHTNESS

4. WHEEZING

5. HEART ATTACK

6. OTHER

Specify ______________________

_____________________________

_____________________________

77. NA

88. DON’T KNOW

99. REFUSED

23c1. When did you go to the hospital (THIRD TIME)?

______/______

mm yyyy

77. NA

88. DON’T KNOW

99. REFUSED