Lung Function Questionnaire

Do you suffer from breathing and/or a frequent cough?

 

These questions ask about your breathing problems and/or a frequent cough. As you answer these questions, please think about how you are feeling physically when you are experiencing these symptoms. For each question, choose the one answer that best describes your symptoms. Share the answers with your doctor or pharmacist.

Step 1. Answer each question with one response and write the score in the box provided next to it.

Step 2. Add the score boxes for your total score.

Step 3- Take the test to your doctor or pharmacist to talk about your score.

 

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1 How often do you cough up mucus

 

Never 5 Rarely 4 Sometimes 3 Often 2 Very Often 1

 

  1. How often does your chest sound noisy (wheezy, whistling, rattling) when you breathe?

 

Never 5 Rarely 4 Sometimes 3 Often 2 Very Often 1
 

3   How often do you experience shortness of breath during physical activity (walking up a flight of stairs or walking up an incline without stopping for a rest)?

 

Never 5 Rarely 4 Sometimes 3 Often 2 Very Often 1

 

  1. How many years have you smoked?

 

Never Smoked 5 10 years or less 4 11-20 Years 3 21-30 Years 2 More than 30 years 1

 

  1. What is your age?

 

Less than 40 years 5 40-49 years 4 50-59 years 3 60-69 years 2 More than 70 years 1

 

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Step 4 · If your score is 18 or less, you may be at risk for a condition that involves airway obstruction. Ask your doctor if you need a simple breathing test. This questionnaire is intended to determine your potential risk. No matter

what your score is, you should still talk to your doctor or pharmacist about your symptoms.