Name & Surname

1.

Do you cough frequently?

2.

Do you get many colds, and do your colds usually last longer than other people's?

3.

Do you often cough up mucous?

4.

Does your breathing sound wheezy, rattling, or whistling?

5.

Do simple activities make you short of breath?

6.

Do you wheeze or become breathless when you exercise or exert yourself?

7.

Do you smoke tobacco, or smoked in the past?

8.

Do you smoke marijuana via combustion of the herb? (Burning, not vapor?)

9.

Do you have a history of exposure to second-hand tobacco smoke?

10.

Have you had chest x-rays, or MRI's? (damage lung DNA via ionizing rads)

11.

Do you experience chest pain when exercising?

12.

History of pneumonia?

13.

Exposure to ammonia, formaldehyde, or toluene diisocyanate?

14.

Have you had pneumonia or bronchitis more than once?

15.

Do you work with or around: lab animals, flour dust, grain dust, glues & resins, latex, wood dust, glutaraldehyde, isocynates (spray paints), chlorine, cutting stone, abrasive blasting, pest control, hair/nail salon chemicals, new carpet, plastics and plastic products, urethane, formaldehyde in building materials?

16.

Do you live in an urban environment of air pollution?