Dyspnea Questionnaire Form
Answer if you are having shortness of breath.
All fields are required.
How long have you had the shortness of breath?
Over the last week
Over the last month
Over the last 3 months
> 6 months
What level of exercise is required to cause the shortness of breath?
Even at rest
Only when I lie down
Walking < one block
Walking > 3 blocks
Only with vigorous exertion
When is the last time you could do the activities that now make you short of breath without having breathing difficulties?
One week ago
One month ago
Within the last 3 months
> 6 months
How far can you walk before you get short of breath?
< one block
between one and four blocks
between four blocks and a mile
> 1 mile
How many steps can you climb before you get short of breath?
< 1 flight
> 2 flights
Does your shortness of breath keep you from being able to complete your work, chores around the house or any other activity that you wish to do?
I don't exercise
I exercise <3 days per week
I exercise 4-5 days per week
I exercise 6-7 days per week
Recent history of bleeding or anemia (low blood counts)?
Past medical history of asthma, emphysema or COPD?
Have you ever been prescribed inhalers of medications to improve your breathing?
If yes to question 11, how much?
> 20 cigarettes/day
Do you smoke cigars/hookah/marijuana?
Illicit drug taking history?
How much alcohol do you drink in one week?
> 14 drinks
Have you worked in an occupation that could have exposed you to excessive dust or harmful particles (e.g.- Farming, Manufacturing, Construction/Plumbing)?
Family history of lung disease/lung problems?
If yes to #16, what color is it?
Pink or red
Do you hear yourself wheeze (the musical/whistling noises when you breath out)?
Have you or any of your contacts ever had TB or a positive TB skin test?
Have you ever been told that you had an abnormal chest x-ray?
Do you get short of breath when lying down? Do you have to use multiple pillows or sleep upright to prevent breathing difficulties?
Have you ever been diagnosed with sleep apnea or been told that you are a loud snorer?
Are you ever woken from sleep with severe shortness of breath to the point that you must sit up to catch your breath?
Do you ever notice a rasping noise heard loudest when taking in a breath that seems to come from neck/throat area?
Do you have ankle swelling?
Do you noticed skipping, rapid, extra, or pounding beats of the heart?
Would you like us to contact you to schedule an appointment?
Your email address:
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