Dyspnea Questionnaire Form

Answer if you are having shortness of breath.
All fields are required.
  1. How long have you had the shortness of breath?
  1. Over the last week
  2. Over the last month
  3. Over the last 3 months
  4. > 6 months
  1. What level of exercise is required to cause the shortness of breath?
  1. Even at rest
  2. Only when I lie down
  3. Walking < one block
  4. Walking > 3 blocks
  5. Only with vigorous exertion
  1. When is the last time you could do the activities that now make you short of breath without having breathing difficulties?
  1. One week ago
  2. One month ago
  3. Within the last 3 months
  4. > 6 months
  1. How far can you walk before you get short of breath?
  1. < one block
  2. between one and four blocks
  3. between four blocks and a mile
  4. > 1 mile
  1. How many steps can you climb before you get short of breath?
  1. < 1 flight
  2. 1-2 flights
  3. > 2 flights
  1. 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?
  1. Yes
  2. No
  1. Exercise history?
  1. I don't exercise
  2. I exercise <3 days per week
  3. I exercise 4-5 days per week
  4. I exercise 6-7 days per week
  1. Recent history of bleeding or anemia (low blood counts)?
  1. Yes
  2. No
  1. Past medical history of asthma, emphysema or COPD?
  1. Yes
  2. No
  1. Have you ever been prescribed inhalers of medications to improve your breathing?
  1. Yes
  2. No
  1. Cigarette smoking?
  1. Yes
  2. No
  1. If yes to question 11, how much?
  1. 1-5 cigarettes/day
  2. 6-10 cigarettes/day
  3. 11-20 cigarettes/day
  4. > 20 cigarettes/day
  1. Do you smoke cigars/hookah/marijuana?
  1. Yes
  2. No
  1. Illicit drug taking history?
  1. Yes
  2. No
  1. How much alcohol do you drink in one week?
  1. None
  2. 1-7 drinks
  3. 8-14 drinks
  4. > 14 drinks
  1. Have you worked in an occupation that could have exposed you to excessive dust or harmful particles (e.g.- Farming, Manufacturing, Construction/Plumbing)?
  1. Yes
  2. No
  1. Family history of lung disease/lung problems?
  1. Yes
  2. No
  1. Cough?
  1. Yes
  2. No
  1. Sputum (Phlegm)?
  1. Yes
  2. No
  1. If yes to #16, what color is it?
  1. Clear
  2. White
  3. Brown
  4. Green
  5. Yellow
  6. Pink or red
  1. Do you hear yourself wheeze (the musical/whistling noises when you breath out)?
  1. Yes
  2. No
  1. Chest pain?
  1. Yes
  2. No
  1. Fever?
  1. Yes
  2. No
  1. Have you or any of your contacts ever had TB or a positive TB skin test?
  1. Yes
  2. No
  1. Have you ever been told that you had an abnormal chest x-ray?
  1. Yes
  2. No
  1. Do you get short of breath when lying down? Do you have to use multiple pillows or sleep upright to prevent breathing difficulties?
  1. Yes
  2. No
  1. Have you ever been diagnosed with sleep apnea or been told that you are a loud snorer?
  1. Yes
  2. No
  1. Are you ever woken from sleep with severe shortness of breath to the point that you must sit up to catch your breath?
  1. Yes
  2. No
  1. Do you ever notice a rasping noise heard loudest when taking in a breath that seems to come from neck/throat area?
  1. Yes
  2. No
  1. Do you have ankle swelling?
  1. Yes
  2. No
  1. Do you noticed skipping, rapid, extra, or pounding beats of the heart?
  1. Yes
  2. No

Would you like us to contact you to schedule an appointment?
Yes No
First Name:
Last Name:
Phone (###-###-####):
Your email address:
(ex: jdoe@sw.org)
Additional comments: