Symptom diary

ATTACHMENT 4

Participant ID: ______________________

Form Approved:

OMB No. 0920-xxxx

Exp. Date xx/xx/2011

DATE (mm/dd/yyyy)
QUESTIONS (In the past 24 hours / hour have you experienced the following:)	1 day pre- commute	MORNING OF commute		1 H Post-commute	2 h post- commute	3 H Post-commute
Waking up at night because of breathing difficulties (e.g., cough, wheeze, shortness of breath)?	  yes no	  yes no
Cough?	  yes no	  yes no	  yes no		  yes no	  yes no
Wheeze?	  yes no	  yes no	  yes no		  yes no	  yes no
Chest tightness?	  yes no	  yes no	  yes no		  yes no	  yes no
Shortness of breath?	  yes no	  yes no	  yes no		  yes no	  yes no
Chest discomfort or pain?	  yes no	  yes no	  yes no		  yes no	  yes no
Palpatations/heart racing?	  yes no	  yes no	  yes no		  yes no	  yes no
Numbness/ tingling in arms or neck?	  yes no	  yes no	  yes no		  yes no	  yes no
Light headedness/ dizziness?	  yes no	  yes no	  yes no		  yes no	  yes no
Other symptom? _________________	  yes no	  yes no	  yes no		  yes no	  yes no
Other symptom? ______________	  yes no	  yes no	  yes no		  yes no	  yes no
12. Medication taken: Name: Dosage:	  yes no	  yes no	  yes no		  yes no	  yes no
13. Medication taken: Name: Dosage:	  yes no	  yes no	  yes no		  yes no	  yes no
14. Medication taken: Name: Dosage:	  yes no	  yes no	  yes no		  yes no	  yes no
15. Did you go to work today?	  yes no	  yes no
16. Did you spend time outside today?	  yes no	  yes no
17. Did you spend time cooking and / or cleaning today?	  yes no	  yes no

Public reporting burden of this collection of information is estimated to average 2 minutes per response, 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; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).