Protocol - Personal and Family History of Respiratory Symptoms/Diseases - Adult

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

1A. Do you usually have a cough? (Count a cough with first smoke or on first going out-of-doors. Exclude clearing of throat.) [If no, skip to question 1C.]

1[ ]Yes

2[ ]No

1B. Do you usually cough as much as 4 to 6 times a day, 4 or more days out of the week?

1[ ]Yes

2[ ]No

1C. Do you usually cough at all on getting up, or first thing in the morning?

1[ ]Yes

2[ ]No

1D. Do you usually cough at all during the rest of the day or at night?

1[ ]Yes

2[ ]No

IF YES TO ANY OF THE ABOVE (1A,1B,1C, OR 1D), ANSWER THE FOLLOWING QUESTIONS. IF NO TO ALL, CHECK DOES NOT APPLY AND SKIP TO 2A.

1E. Do you usually cough like this on most days for 3 consecutive months or more during the year?

1[ ]Yes

2[ ]No

8[ ]Does not apply

1F. For how many years have you had this cough?

_____________ Number of years

88[ ]Does not apply

PHLEGM

2A. Do you usually bring up phlegm from your chest? (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 2C.]

1[ ]Yes

2[ ]No

2B. Do you usually bring up phlegm like this as much as twice a day, 4 or more days out of the week?

1[ ]Yes

2[ ]No

2C. Do you usually bring up phlegm at all on getting up or first thing in the morning?

1[ ]Yes

2[ ]No

2D. Do you usually bring up phlegm at all during the rest of the day or at night?

1[ ]Yes

2[ ]No

IF YES TO ANY OF THE ABOVE (2A, 2B, 2C, OR 2D), ANSWER THE FOLLOWING. IF NO TO ALL, CHECK DOES NOT APPLY AND SKIP TO 3A.

2E. Do you bring up phlegm like this on most days for 3 consecutive months or more during the year?

1[ ]Yes

2[ ]No

8[ ]Does not apply

2F. For how many years have you had trouble with phlegm?

_____________ Number of years

88[ ]Does not apply

EPISODES OF COUGH AND PHLEGM

3A. Have you had periods or episodes of (increased*) cough and phlegm lasting for 3 weeks or more each year? (*For individuals who usually have cough and/or phlegm)

1[ ]Yes

2[ ]No

IF YES TO 3A:

3B. For how long have you had at least 1 such episode per year?

_____________ Number of years

88[ ]Does not apply

WHEEZING

4A. Does your chest ever sound wheezy or whistling:

1. When you have a cold?

1[ ]Yes

2[ ]No

2. Occasionally apart from colds?

1[ ]Yes

2[ ]No

3. Most days or nights?

1[ ]Yes

2[ ]No

IF YES TO 1, 2, OR 3 IN 4A:

4B. For how many years has this been present?

____________ Number of years

88[ ]Does not apply

5A. Have you ever had an ATTACK of wheezing that has made you feel short of breath?

1[ ]Yes

2[ ]No

IF YES TO 5A:

5B. How old were you when you had your first such attack?

_______ Age in years

88[ ]Does not apply

5C. Have you had 2 or more such episodes?

1[ ]Yes

2[ ]No

8[ ]Does not apply

5D. Have you ever required medicine or treatment for the(se) attack(s)?

1[ ]Yes

2[ ]No

8[ ]Does not apply

BREATHLESSNESS

6. If disabled from walking by any condition other than heart or lung disease, please describe and proceed to Question 8A.

_________________________________________________ Nature of condition(s):

7A. 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 7A:

7B. Do you have to walk slower than people of your age on the level because of breathlessness?

1[ ]Yes

2[ ]No

8[ ]Does not apply

7C. Do you ever have to stop for breath when walking at your own pace on the level?

1[ ]Yes

2[ ]No

8[ ]Does not apply

7D. Do you ever have to stop for breath after walking about 100 yards (or after a few minutes) on the level?

1[ ]Yes

2[ ]No

8[ ]Does not apply

7E. Are you too breathless to leave the house or breathless on dressing or undressing?

1[ ]Yes

2[ ]No

8[ ]Does not apply

CHEST COLDS AND CHEST ILLNESSES

8A. If you get a cold, does it usually go to your chest? (Usually means more than 1/2 the time.)

1[ ]Yes

2[ ]No

8[ ]Don’t get colds

9A. During the past 3 years, have you had any chest illnesses that have kept you off work, indoors at home, or in bed?

1[ ]Yes

2[ ]No

IF YES TO 9A:

9B. Did you produce phlegm with any of these chest illnesses?

1[ ]Yes

2[ ]No

8[ ]Does not apply

9C. In the last 3 years, how many such illnesses, with (increased) phlegm, did you have which lasted a week or more?

_____ Number of illnesses

_____ No such illnesses

8[ ]Does not apply

PAST ILLNESSES

10. Did you have any lung trouble before the age of 16?

1[ ]Yes

2[ ]No

11. Have you ever had any of the following:

1A. Attacks of bronchitis?

1[ ]Yes

2[ ]No

IF YES TO 1A:

1B. Was it confirmed by a doctor?

1[ ]Yes

2[ ]No

8[ ]Does not apply

1C. 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:

2B. Was it confirmed by a doctor?

1[ ]Yes

2[ ]No

8[ ]Does not apply

2C. At what age did you first have it?

______ Age in years

88[ ]Does not apply

3A. Hay fever?

1[ ]Yes

2[ ]No

IF YES TO 3A:

3B. Was it confirmed by a doctor?

1[ ]Yes

2[ ]No

8[ ]Does not apply

3C. At what age did it start?

______ Age in years

88[ ]Does not apply

12A. Have you ever had chronic bronchitis?

1[ ]Yes

2[ ]No

IF YES TO 12A:

12B. Do you still have it?

1[ ]Yes

2[ ]No

8[ ]Does not apply

12C. Was it confirmed by a doctor?

1[ ]Yes

2[ ]No

8[ ]Does not apply

12D. At what age did it start?

______ Age in years

88[ ]Does not apply

13A. Have you ever had emphysema?

1[ ]Yes

2[ ]No

IF YES TO 13A:

13B. Do you still have it?

1[ ]Yes

2[ ]No

8[ ]Does not apply

13C. Was it confirmed by a doctor?

1[ ]Yes

2[ ]No

8[ ]Does not apply

13D. At what age did it start?

______ Age in years

88[ ]Does not apply

14A. Have you ever had asthma?

1[ ]Yes

2[ ]No

IF YES TO 14A:

14B. Do you still have it?

1[ ]Yes

2[ ]No

8[ ]Does not apply

14C. Was it confirmed by a doctor?

1[ ]Yes

2[ ]No

8[ ]Does not apply

14D. At what age did it start?

______ Age in years

88[ ]Does not apply

14E. If you no longer have it, at what age did it stop?

______ Age stopped

88[ ]Does not apply

15. Have you ever had:

15A. Any other chest illnesses?

1[ ]Yes

2[ ]No

If yes, please specify ____________________________________________

15B. Any chest operations?

1[ ]Yes

2[ ]No

If yes, please specify ____________________________________________

15C. Any chest injuries?

1[ ]Yes

2[ ]No

If yes, please specify ____________________________________________

16A. Has doctor ever told you that you had heart trouble?

1[ ]Yes

2[ ]No

IF YES to 16A:

16B. Have you ever had treatment for heart trouble in the past 10 years?

1[ ]Yes

2[ ]No

8[ ]Does not apply

17A. Has a doctor ever told you that you have high blood pressure?

1[ ]Yes

2[ ]No

IF YES to 17A:

17B. Have you had any treatment for high blood pressure (hypertension) in the past 10 years?

1[ ]Yes

2[ ]No

8[ ]Does not apply

OCCUPATIONAL HISTORY

18A. Have you ever worked full time (30 hours per week or more) for 6 months or more?

1[ ]Yes

2[ ]No

IF YES to 18A:

18B. Have you ever worked for a year or more in any dusty job?

1[ ]Yes

2[ ]No

8[ ]Does not apply

_________________________ Specify job/industry

___ Total years worked

Was dust exposure

1[ ]Mild?

2[ ]Moderate?

3[ ]Severe?

18C. Have you ever been exposed to gas or chemical fumes in your work?

1[ ]Yes

2[ ]No

8[ ]Does not apply

_________________________ Specify job/industry

___ Total years worked

Was fume exposure

1[ ]Mild?

2[ ]Moderate?

3[ ]Severe?

18D. 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

19A. Have you ever smoked cigarettes? (NO means less than 20 packs of cigarettes or 12 oz. of tobacco in a lifetime or less than 1 cigarette a day for 1 year.)

1[ ]Yes

2[ ]No

IF YES to 19A:

19B. Do you now smoke cigarettes (as of 1 month ago)?

1[ ]Yes

2[ ]No

8[ ]Does not apply

19C. How old were you when you first started regular cigarette smoking?

____ Age in Years

88[ ]Does not apply

19D. If you have stopped smoking cigarettes completely, how old were you when you stopped?

____ Age stopped

[ ] Check if still smoking

88[ ]Does not apply

19E. How many cigarettes do you smoke per day now?

___ Cigarettes/day

88[ ]Does not apply

19F. On the average of the entire time you smoked, how many cigarettes did you smoke per day?

___ Cigarettes/day

88[ ]Does not apply

19G. Do or did you inhale the cigarette smoke?

1[ ]Does not apply

2[ ]Not at all

3[ ]Slightly

4[ ]Moderately

5[ ]Deeply

20A.Have you ever smoked a pipe regularly?

1[ ]Yes (YES means more than 12 oz. tobacco in a lifetime.)

2[ ]No

IF YES to 20A:

20B1. How old were you when you started to smoke a pipe regularly?

____ Age

20B2. If you have stopped smoking a pipe completely, how old were you when you stopped?

____ Age stopped

Check if still smoking pipe ____

88[ ]Does not apply __

20C. On the average over the entire time you smoked a pipe, how much pipe tobacco did you smoke per week?

____ oz. per week (a standard pouch of tobacco contains 1 1/2 oz.)

88[ ]Does not apply ___

20D. How much pipe tobacco are you smoking now?

___ oz. per week

88[ ]Not currently smoking a pipe ___

20E. Do or did you inhale the pipe smoke?

1[ ]Never smoked

2[ ]Not at all

3[ ]Slightly

4[ ]Moderately

5[ ]Deeply

21A. Have you ever smoked cigars regularly?

1[ ]Yes (YES means more than 1 cigar a week for a year.)

2[ ]No

IF YES to 21A:

21B1. How old were you when you started smoking cigars regularly?

____ Age

21B2. If you have stopped smoking cigars completely, how old were you when you stopped?

____ Age stopped

Check if still smoking cigars___

88[ ]Does not apply __

21C. On the average over the entire time you smoked cigars, how many cigars did you smoke per week?

___ Cigars per week

88[ ]Does not apply

21D. How many cigars are you smoking per week now?

___ Cigars per week

88[ ]Check if not smoking cigars currently

21E. Do or did you inhale the cigar smoke?

1[ ]Never smoked

2[ ]Not at all

3[ ]Slightly

4[ ]Moderately

5[ ]Deeply

FAMILY HISTORY

22. Were either of your natural parents ever told by a doctor that they had a chronic lung condition such as:

FATHER

22A. Chronic bronchitis?

1[ ]Yes

2[ ]No

3[ ]Don’t know

22B. Emphysema?

1[ ]Yes

2[ ]No

3[ ]Don’t know

22C. Asthma?

1[ ]Yes

2[ ]No

3[ ]Don’t know

22D. Lung cancer?

1[ ]Yes

2[ ]No

3[ ]Don’t know

22E. Other chest conditions?

1[ ]Yes

2[ ]No

3[ ]Don’t know

MOTHER

22A. Chronic bronchitis?

1[ ]Yes

2[ ]No

3[ ]Don’t know

22B. Emphysema?

1[ ]Yes

2[ ]No

3[ ]Don’t know

22C. Asthma?

1[ ]Yes

2[ ]No

3[ ]Don’t know

22D. Lung cancer?

1[ ]Yes

2[ ]No

3[ ]Don’t know

22E. Other chest conditions?

1[ ]Yes

2[ ]No

3[ ]Don’t know

23. Have you ever had wheezing or whistling in your chest?

1[ ]Yes

2[ ]No

If Yes, about how old were you when you first had wheezing or whistling in your chest?

_____ Age in years (Answer 1 if younger than age 1 year)

24. In the last 12 months, have you had wheezing or whistling in your chest at any time?

1[ ]Yes

2[ ]No

If Yes, in the last 12 months, does your chest ever sound wheezy or whistling:

When you have a cold?

1[ ]Yes

2[ ]No

More than once a week?

1[ ]Yes

2[ ]No

Most days and nights?

1[ ]Yes

2[ ]No

25. In the last 12 months, have you been awakened from sleep by coughing, apart from a cough associated with a cold or chest infection?

1[ ]Yes

2[ ]No

26. In the last 12 months, have you been awakened from sleep by shortness of breath or a feeling of tightness in your chest?

1[ ]Yes

2[ ]No

27. In the past 12 months, have you been bothered by sneezing or a runny or blocked nose when you did not have a cold or the flu?

1[ ]Yes

2[ ]No

28. In the past 12 months, have you been bothered by watery, itchy, or burning eyes when you did not have a cold or the flu?

1[ ]Yes

2[ ]No

29. In the past 12 months, have you had periods or episodes of cough with phlegm that lasted 1 week or more? (If you usually have cough and phlegm, please count only periods or episodes of increased cough and phlegm.)

1[ ]Yes

2[ ]No

If Yes, for how many years have you had at least one such episode per year?

Number of years___

If Yes, about how many such episodes have you had in the past 12 months?

Number of episodes ___

30. In the past year, have you been to the emergency room or hospitalized for lung problems?

1[ ]Yes

2[ ]No

If Yes, how many times? ___

31. In the past year, have you been treated with antibiotics for a chest illness?

1[ ]Yes

2[ ]No

If Yes, how many times? ___

32. In the past year, have you been treated with steroid pills or injections, such as prednisone or solumedrol, for a chest illness?

1[ ]Yes

2[ ]No

If Yes, how many times? ___