|-----------------------------------------------------------------------------| | ATS-DLD-78-A | | ADULT QUESTIONNAIRE - SELF COMPLETION | | (for those 13 years of age and older) | | Thank you for your willingness to participate. You were selected | | by a scientific sampling procedure, and your cooperation is very | | important to the success of this study. | | This is a questionnaire you are asked to fill out. Please answer | | the questions as frankly and accurately as possible. ALL INFORMATION | | OBTAINED IN THE STUDY WILL BE KEPT CONFIDENTIAL AND USED FOR MEDICAL | | RESEARCH ONLY. Your personal physician will be informed about the test | | results if you desire. | |-----------------------------------------------------------------------------| IDENTIFICATION IDENTIFICATION NUMBER: ##### NAME:_________________________ ________________________ ___ (Last) (First) (MI) STREET ______________________________________________________ CITY ____________________________ STATE ____ ZIP _______ PHONE NUMBER: ( ) ______-__________ INTERVIEWER: ### DATE: ___________________ MO DAY YR ============================================================================== 1. BIRTHDATE: _____ ____ ______ Month Day Year 2. Place of Birth: _______________________________ 3. Sex: 1. Male ____ 2. Female ____ 4. What is your marital status? 1. Single ____ 2. Married ____ 3. Widowed ____ 4. Separated/Divorced ____ 5. Race: 1. White ____ 2. Black ____ 3. Oriental ____ 4. Other ____ 6. What is the highest grade completed in school? __________ (For example: 12 years is completion of high school) ============================================================================== SYMPTOMS These questions pertain mainly to your chest. Please answer yes or no if possible. If a question does not appear to be applicable to you, check the does not apply space. If you are in doubt about whether your answer is yes or no, record no. COUGH 7A. Do you usually have a cough? 1. Yes ___ 2. No ___ (Count a cough with first smoke or on first going out-of-doors. Exclude clearing of throat.)[If no, skip to question 7C.] B. Do you usually cough as much as 4 to 6 times a 1. Yes ___ 2. No ___ day, 4 or more days out of the week? C. Do you usually cough at all on getting up, or 1. Yes ___ 2. No ___ first thing in the morning? D. Do you usually cough at all during the rest 1. Yes ___ 2. No ___ of the day or at night? IF YES TO ANY OF THE ABOVE(7A,7B,7C, OR 7D), ANSWER THE FOLLOWING: IF NO TO ALL, CHECK DOES NOT APPLY AND SKIP TO 8A. E. Do you usually cough like this on most days for 1. Yes ___ 2. No ___ 5 consecutive months or more during the year? 8. Does not apply __ F. For how many years have you had this cough? ____________________ Number of years 88. Does not apply __ ================================================================================ PHLEGM 8A. Do you usually bring up phlegm from your chest? 1. Yes ___ 2. No ___ (Count phlegm with the first smoke or on first going out-of-doors. Exclude phlegm from the nose. Count swallowed phlegm) [If no, skip to 8C.] B. Do you usually bring up phlegm like this as 1. Yes ___ 2. No ___ much as twice a day, 4 or more days out of the week? C. Do you usually bring up phlegm at all on get- 1. Yes ___ 2. No ___ ting up or first thing in the morning? D. Do you usually bring up phlegm at all during 1. Yes ___ 2. No ___ the rest of the day or at night? IF YES TO ANY OF THE ABOVE (8A, B, C, OR D), ANSWER THE FOLLOWING: IF NO TO ALL, CHECK DOES NOT APPLY AND SKIP TO 9A. E. Do you bring up phlegm like this on most days 1. Yes ___ 2. No ___ for 3 consecutive months or more during the year? 8. Does not apply __ F. For how many years have you had trouble with ____________________ phlegm? Number of years 88. Does not apply __ ============================================================================== EPISODES OF COUGH AND PHLEGM 9A. Have you had periods or episodes of (in- 1. Yes ___ 2. No ___ creased*) cough and phelgm lasting for 3 weeks or more each year? *(For individuals who usually have cough and/or phlegm) IF YES TO 9A: B. For how long have you had at least 1 such ____________________ episode per year? Number of years 88. Does not apply __ ============================================================================== WHEEZING 10A. Does your chest ever sound wheezy or whis- tling: 1. When you have a cold? 1. Yes ___ 2. No ___ 2. Occaisonally apart from colds? 1. Yes ___ 2. No ___ 3. Most days or nights? 1. Yes ___ 2. No ___ IF YES TO 1, 2, OR 3 IN 10A: B. For how many years has this been present? ____________________ Number of years 88. Does not apply __ 11A. Have you ever had an ATTACK of wheezing that 1. Yes ___ 2. No ___ has made you feel short of breath? IF YES TO 11A: B. How old were you when you had your first _______ Age in years such attack? 88. Does not apply __ C. Have you had 2 or more such episodes? 1. Yes ___ 2. No ___ 8. Does not apply __ D. Have you ever required medicine or treatment 1. Yes ___ 2. No ___ for the(se) attack(s)? 8. Does not apply __ ============================================================================== BREATHLESSNESS 12. If disabled from walking by any condition other than heart or lung disease, please describe and proceed to Question 14A. Nature of condition(s):__________________________________________________ 13A. Are you troubled by shortness of breath when hurrying on the level or walking up a slight hill? 1. Yes ___ 2. No ___ IF YES TO 13A: B. Do you have to walk slower than people of your 1. Yes ___ 2. No ___ age on level because of breathlessness? 8. Does not apply __ C. Do you ever have to stop for breath when walk- 1. Yes ___ 2. No ___ ing at your own pace on the level? 8. Does not apply __ D. Do you ever have to stop for breath after walk 1. Yes ___ 2. No ___ ing about 100 yards(or after a few minutes) on 8. Does not apply __ the level? E. Are you too breathless to leave the house or 1. Yes ___ 2. No ___ breathless on dressing or undressing? 8. Does not apply __ ============================================================================== CHEST COLDS AND CHEST ILLNESSES 14A. If you get a cold, does it usually go to your 1. Yes ___ 2. No ___ chest? (Usually means more than 1/2 the time) 8. Don't get colds__ 15A. During the past 3 years, have you had any 1. Yes ___ 2. No ___ chest illnesses that have kept you off work, in- doors at home, or in bed? IF YES TO 15A: B. Did you produce phlegm with any of these 1. Yes ___ 2. No ___ chest illnesses? 8. Does not apply __ C. In the last 3 years, how many such illnesses, _____Number of illnesses with (increased) phlegm, did you have which _____No such illnesses lasted a week or more? _____Does not apply ============================================================================== PAST ILLNESSES 16. Did you have any lung trouble before the age 1. Yes ___ 2. No ___ of 16? 17. Have you ever had any of the following: 1A. Attacks of Bronchitis? 1. Yes ___ 2. No ___ IF YES TO 1A: B. Was it confirmed by a doctor? 1. Yes ___ 2. No ___ 8. Does not apply __ C. At what age was your first attack? ______ Age in years 88. Does not apply __ 2A. Pneumonia (include bronchopneumonia)? 1. Yes ___ 2. No ___ IF YES TO 2A: B. Was it confirmed by a doctor? 1. Yes ___ 2. No ___ 8. Does not apply __ C. At what age did you first have it? ______ Age in years 88. Does not apply __ 3A. Hayfever? 1. Yes ___ 2. No ___ IF YES TO 3A: B. Was it confirmed by a doctor? 1. Yes ___ 2. No ___ 8. Does not apply __ C. At what age did it start? ______ Age in years 88. Does not apply __ 18A. Have you ever had chronic bronchitis? 1. Yes ___ 2. No ___ IF YES TO 18A: B. Do you still have it? 1. Yes ___ 2. No ___ 8. Does not apply __ C. Was it confirmed by a doctor? 1. Yes ___ 2. No ___ 8. Does not apply __ D. At what age did it start? ______ Age in years 88. Does not apply __ 19A. Have you ever had emphysema? 1. Yes ___ 2. No ___ IF YES TO 19A: B. Do you still have it? 1. Yes ___ 2. No ___ 8. Does not apply __ C. Was it confirmed by a doctor? 1. Yes ___ 2. No ___ 8. Does not apply __ D. At what age did it start? ______ Age in years 88. Does not apply __ 20A. Have you ever had asthma? 1. Yes ___ 2. No ___ IF YES TO 20A: B. Do you still have it? 1. Yes ___ 2. No ___ 8. Does not apply __ C. Was it confirmed by a doctor? 1. Yes ___ 2. No ___ 8. Does not apply __ D. At what age did it start? ______ Age in years 88. Does not apply __ E. If you no longer have it, at what age did it ______ Age stopped stop? 88. Does not apply __ 21. Have you ever had: A. Any other chest illnesses? 1. Yes ___ 2. No ___ If yes, please specify ____________________________________________ B. Any chest operations? 1. Yes ___ 2. No ___ If yes, please specify ____________________________________________ C. Any chest injuries? 1. Yes ___ 2. No ___ If yes, please specify ____________________________________________ 22A. Has doctor ever told you that you had heart 1. Yes ___ 2. No ___ trouble? IF YES to 22A: B. Have you ever had treatment for heart trouble 1. Yes ___ 2. No ___ in the past 10 years? 8. Does not apply __ 23A. Has a doctor ever told you that you have high 1. Yes ___ 2. No ___ blood pressure? IF YES to 23A: B. Have you had any treatment for high blood 1. Yes ___ 2. No ___ pressure (hypertension) in the past 10 years? 8. Does not apply __ ============================================================================== OCCUPATIONAL HISTORY 24A. Have you ever worked full time (30 hours per 1. Yes ___ 2. No ___ week or more) for 6 months or more? IF YES to 24A: B. Have you ever worked for a year or more in 1. Yes ___ 2. No ___ any dusty job? 8. Does not apply __ Specify job/industry: _________________________ Total years worked __ Was dust exposure 1. Mild ___ 2. Moderate ___ 3. Severe ___ ? C. Have you ever been exposed to gas or chemical 1. Yes ___ 2. No ___ fumes in your work? 8. Does not apply __ Specify job/industry: _________________________ Total years worked __ Was dust exposure 1. Mild ___ 2. Moderate ___ 3. Severe ___ ? D. What has been your usual occupation or job -- the one you have worked at the longest? 1. Job-occupation: __________________________________________________ 2. Number of years employed in this occupation:______________________ 3. Position-job title: ______________________________________________ 4. Business, field, or industry: ____________________________________ ============================================================================== TOBACCO SMOKING 25A. Have you ever smoked cigarettes? (NO means 1. Yes ___ 2. No ___ less than 20 packs of cigarettes or 12 oz. of tobacco in a lifetime or less than 1 cigarette a day for 1 year. IF YES to 25A: B. Do you now smoke cigarettes (as of 1 month 1. Yes ___ 2. No ___ ago)? 8. Does not apply __ C. How old were you when you first started reg- ____ Age in Years cigarette smoking? 88.Does not apply __ D. If you have stopped smoking cigarettes com- ____ Age stopped pletely, how old were you when you stopped? Check if still smoking ___ 88.Does not apply __ E. How many cigarettes do you smoke per day now? ___ Cigarettes/day 88.Does not apply __ F. On the average of the entire time you smoked, ___ Cigarettes/day how many cigarettes did you smoke per day? 88.Does not apply __ G. Do or did you inhale the cigarette smoke? 1. Does not apply __ 2. Not at all ______ 3. Slightly ________ 4. Moderately ______ 5. Deeply __________ 26A. Have you ever smoked a pipe regularly? 1. Yes ___ 2. No ___ (YES means more than 12 oz tobacco in a lifetime.) IF YES to 26A: B1. How old were you when you started to ____ Age smoke a pipe regularly? 2. If you have stopped smoking a pipe com- ____ Age stopped pletely, how old were you when you stopped? Check if still smoking pipe ____ 88.Does not apply __ C. On the average over the entire time you ____ oz per week (a stan- smoked a pipe, how much pipe tobacco did dard pouch of tobacco con- you smoke per week ? tains 1 1/2 oz) 88.Does not apply __ D. How much pipe tobacco are you smoking now? ___ oz per week 88. Not currently smoking a pipe ___ E. Do or did you inhale the pipe smoke? 1. Never smoked ____ 2. Not at all ______ 3. Slightly ________ 4. Moderately ______ 5. Deeply __________ 27A. Have you ever smoked cigars regularly? 1. Yes ___ 2. No ___ (Yes means more than 1 cigar a week for a year). IF YES to 27A: B1. How old were you when you started smok- ____ Age ing cigars regularly? 2. If you have stopped smoking cigars com- ____ Age stopped pletely, how old were you when you stopped? Check if still smoking cigars___ 88.Does not apply __ C. On the average over the entire time you ___ Cigars per week smoked cigars, how many cigars did you smoke 88.Does not apply __ per week ? D. How many cigars are you smoking per week ___ Cigars per week now? 88. Check if not smoking cigars currently __ E. Do or did you inhale the cigar smoke? 1. Never smoked ____ 2. Not at all ______ 3. Slightly ________ 4. Moderately ______ 5. Deeply __________ ============================================================================== FAMILY HISTORY 28. Were either of your natural parents ever told by a doctor that they had a chronic lung condition such as: FATHER MOTHER 1. YES 2. NO 3. DON'T 1. YES 2. NO 3. DON'T KNOW KNOW A. Chronic brochitis? _____ _____ _______ _____ _____ _______ B. Emphysema? _____ _____ _______ _____ _____ _______ C. Asthma? _____ _____ _______ _____ _____ _______ D. Lung cancer? _____ _____ _______ _____ _____ _______ E. Other chest conditions? _____ _____ _______ _____ _____ _______ 29A. Is parent currently alive? _____ _____ _______ _____ _____ _______ B. Please Specify: _____ Age if living _____ Age if living _____ Age at death _____ Age at death 8. Don't know _____ 8. Don't know _____ C. Please specify cause of death. ________________________________ _________________________ ===============================================================================