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: :............... |