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Please check the number of the response that best describes how you have been feeling during the past week.
(Only one response for each question). |
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On average, during the past week, how often did you feel: |
never |
hardly ever |
a few times |
several times |
many times |
a great many times |
almost all the time |
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1. Short of breath at rest? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
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2. Short of breath doing physical activities? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
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3. Concerned about getting a cold or your breathing getting worse? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
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4. Depressed (down) because of your breathing problems? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
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In general, during the past week, how much of the time: |
never |
hardly ever |
a few times |
several times |
many times |
a great many times |
almost all the time |
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5. Did you cough? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
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6. Did you produce phlegm? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
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On average, during the past week, how limited were you in these activities because of your breathing problems: |
not limited at all |
very slightly limited |
slightly limited |
modera-tely limited |
very limited |
extremely limited |
totally limited /or unable to do |
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7. Strenuous physical activities (such as climbing stairs, hurrying, doing sports)? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
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8. Moderate physical activities (such as walking, housework, carrying things)? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
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9. Daily activities at home (such as dressing, washing yourself)? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
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10. Social activities (such as talking, being with children, visiting friends/ relatives)? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
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