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Table 2 Questionnaire used for the assessment of history, smoking habit, family history and treatment.

From: A telehealth integrated asthma-COPD service for primary care: a proposal for a pilot feasibility study in Crete, Greece

1st visit Questionnaire

1. What medication do you use?

   □ None I do not use medication

   □ Yes,

Name medicine

Dosis

Frequency

2. Have you ever smoked for longer than 1 year?

   □ Never

   □ Yes but I stopped smoking since: ..............

   □ Yes I smoke

3. How often last year did you receive antibiotics and/or prednisolone prescribed because of your pulmonary problems ? ...................times

4. At which age did your pulmonary problems appear for the first time? I was ..... (age) years old.

5. Have you ever been diagnosed with eczema, hay fever, allergy, asthma, COPD or bronchitis?

   □ No

   □ Yes (please mark the subject)

6. Does your family (parents, brothers, sisters) suffer from pulmonary problems?

   □ No

   □ Yes

   □ I do not know

7. What is or was your occupation?

....................................................................................

8. Due to what or when do you experience symptoms such as being short of breath, wheeze, mark if yes.

â–¡ springtime

â–¡ wheeds

â–¡ cigarette smoke

â–¡ summer

â–¡ trees

â–¡ paint

â–¡ food

â–¡ cold air

â–¡ perfume

â–¡ pet animals

â–¡ fog

â–¡ exercise

â–¡ dust (house)

â–¡ cooking scent

â–¡ other: :...............