W a w ~• z o P

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o r~a W a U W d cn ❑ .o H z H cn

~ r~a oW~JA ~~ ~ ~ cwi cwi ~ o

H Z k+ H a z z O -- H N

°

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w P. H~n O w 5d x A A o a H N oG o

.a xd z >+ 0~

P4

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a H W ► 7 cn ~

n vi 0~ U tn w c:1 H v~ U (n 6 x7 3 W' oG 3 F-4 O tn LL ~ dV)

rX4

5 1 5 ~

p,' H W c•'1 N d ~n V)

Z d Y~ N~ H W

0o a ax w aHV) P-1

W

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r~ W w ocn w

w

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Q O O

21 "J A A w W C> 60 d O H 0 W H W

w C4 C4

cn 0 ~ v a A ~ A t~~. A 0 t~. Z/~ aC ~ SWG OU L~.

2 M

5 7 /~ h .l

5 C 17 f f e c J Jl J yY )C Jl )~ )S ~' )c 1 1

)s 3 S' All f 7S 4Ll-J VJ / U~/ VS l 41 4

04 W vl vl

N

W w' ~G W O

z

cQ W vUi H zH z d W x d

0 U f ~ Z H

(14 0

W C/

t(n ]q 0 Z 0 F-4 ) ? H ~ ~ O H O a a' H H x a~;

W ~ W W' ~

Lf)

H w' w z H ~+ N H ~ Q H cs',

0 > P, III F

W o0 W C~ aW: Z W Wcn r~ q

4

C9 CJ c~ cn ~ d ::D U

C14

cn 0cn cn

:D W

~

-FF WEEK PRIOR

ON ENTRY 4 ON ENTRY

IN CHAMBER 5 IN CHAMBER

ON EXITING 61 1 cJ I 1 ON EXITING

1 IIOUR POST 1 HOUR POS T

2 HOUR POST 2 HOUR POST -ItE

3 IIOUR POST 9 3 HOUR POST

DAY POST 1 0 I O ~ ~ ~ I I I I _DAY POST _

WEEK POST 1 1 0 1111 1 IJEEK POST
N ~

E4 914

T

w ^ ' a w A°° a p.2 ~

' ~ I x

E ~ 3 k

w wd

PQ W A H

a}+vl C o

En v -4 V U U a O t

-3 Hz H cn F

n

V L

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.+ O D U H H W W ,.f oG d Z >+

A ° O W H N PG 0 ~

>+ v

r a x w

L O a W w cn O U W O~-+

AdC~. cxilv U) 6 x 3 rx c 3 Ho vi a dx~ v

S 1 -

(y ~ ~

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w ~

y' d ~>+a H

N Q [N cn ~ •

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co cu c~ a a ] H cn ~ E ~+ oG Z

v~ Cil x H>+

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a0 W CL H ., a~ ¢

Hd W O ap En u d Z

H O[n Z\ P w N > cn >

w a Z z

W U cp W

. w -' w U w c~ w x • x [ O

"~ w C9 O(9 O' C9 O' C9 O H U a Cl A A w .~ H H x E . W , U

~ 0 ~ U v a NO w a a w U cn W ~ 5C ~ ~ C ) w W Y wwx rl~ 04 x w~x xOulOx w ~w °O w Fd-.

~ c, U oG p A k Y . A [.. A c=. A k. Z n x 3 x w ~ ~ U k+ Q

ppF2 1 ~ : :ii:i:

ca ~~ r - C f7 c I~ c tIL ir l» lf J )c il 1i- 3) j5 ia J 9f 4a l 41 y S 2 Sf 5~

w v~

w ~ ~

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0

H ~ ~ i U H H o ~ ~ H Z' H H r,' ~ ~

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0 ::D

t/] En 0 a4 =3 0

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ON EiITRY 4 1

S h WEEK PRIOR

ON ENT R Y

IN CHAMBER 5 1 +1 IN CHAMBE R

ON EXITING ~ ~ 5 1 I -

ON EXITING

1 110UR POST

1 HOUR POST

2 HOUR POST

2 HOUR POST

3 HOUR POST 9 _ 3 HOUR POST

.DAY POST 1 0 POST

WEEK POST 1 O I O 110 Il EEK POST

I
~

il c~ w .~ 1 z o n p 3 rtS 00 _ •~ • W O H

'4

w' W o W L.3 - O?G >+ P. • tn ~-] W A

n am w oL U W¢ ~+ cn C a ,...~ H Z cn H

~ ~ w O W ~ A H v ~ U U c¢i O~ ~ ~

L H z H a z z O ~ H c~

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U

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co: A ~ A rA~ cn O~ W ~ A C~ C9 H H ~4 pO A ~G >G W W H R, avP; O

F-4

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v

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x x cn

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w ~ a'aH"

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w' o a cn

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H

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0

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m -3

H

P4 U

C1 04 w

D ~ a~ aiw~w w `n H ¢~ ~ z

a ww~cnw0 a a0o o ~ H N Ln c~ U r~ tn ¢ :D U cn rn W cn (n c~ .

ON ENTRY O

WEEK PRIOR

N ENTRY

IN CHAMBER 5 `~ ~ ~ ID 5 ~~ I

ON EXITING ~

IN CHAMBER

1 IIOUR POST -

5

4

--ON EXITI N G

1 HOUR POST

2 HOUR POST 2 HOUR POST

3 HOUR POST 9 ~" - - 3 HOUR POST

DAY POST 1 0 DAY POST

WEEK POST 1 1 _ I ~ ~ I I I j l I i I I -WEEK POST _

-1 2
n' ,~w c~w ~ z o . tt: w p W • W O H

~D p

l .7 -' • W M A O . 4 SL r•+ 0.. ^ N .~ W A

r7 W W oL U W d ~+ V7 C7 p H Z H v7

co 0 A H v) .14 1-4 W W ~ A O v) p6G

U O l+

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r W W H v7 O W ~7 x A A O P

. O D U H H W W ..] W. d Z

CI& >4 .

n ~ ~ A cn O W . H N oG O c>~ O . a

N

7 A C~ C~ H H AL 0 A aL >L W W H W

Lo v7 U) w A H ~ U cw/7 ¢

0 2

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{~ ., v X

U)l

d

W c'1 N d tN (n

>4 N A H W

W I Z

c~ m cu w w w

W w w' W W O

.a H cn w ~j ~ H>+

00 W > P, x H d W W

.-7 U) w W cn \ .-7 .-l W d O

w.• O cHn >cHi7 O U W O tn

H H • W H W V W W W 0 ~14

~ '7 5 Cl W W (, O 0 O 0 d(, d H xV a W ~ d PL

-- ~ d F.

Z no 0 V V A A 6

H O aG ~

W a ty ~ W U cn W SG W O W

Ln En

W W p: c>~ w' w a5 w' w w O v~ O x W W H H \ r~ H

U U w' t>; A t

x~

2 3

A tL A w A [. Z n x 3 x ~ v tv d

s L

IF, 17 a

/' a) tt 1 YY l Au > t if 7 il lt 3 1514,13 7113 VL .i~ 4l i Of Vj l 41 4 - S 2 SS

d' w In Wc~i7 Z

W U H~ • 0 PQ d7 z

i f

z d w x d

F-4 (n F4

H

Z

O

~+

H w' H~

O d • W v7

k/7]

0 0

x Z Z H x

C.~ 1-+ W H

c~

r u a H rx

W O ''t

C4 x ~ O z H y+ cHi H ~ d H u

:D A U W M W C.7 W z W cn H

0 -~c m cl, ~:) z

cn ~ C~ ~ Ri V7 ~ Q 5 U n.' 04ti7

0

c0l7 0 -1~ o f+¢. ]d W ~

WEEK PRIOR

UN ENTRY 4 ON ENTR Y

I }J CIU1t•1liER 5 O O~ i \I \\ ~ \I IN CHAMBER

ON EXITING ON EXI TIN

G 1 HOUR POST 1 HOUR POS T

2 IIOUR POST 2 HOUR POST

3 HOUR POST 9 3 HOUR POST

0/1Y PUST 1 0 V I ~ I I ~~~ (0) DAY POST

WEEK POST IIEEK POST
p. 5

Deoaion

Table C-7 x g" -) /

PHYSIOLOGICAL AND SYMPTOM RESPONSES OF SUBJECT 879

A MINIMAL/MILD ASTHMATIC, GROUP #3

SR• . SGORES FOR SVEJECT HIAAER 07t

(• . .. .«I/ .11c e•th~ytlc - / r .~e /!)

RQIO /1 SR . . SCORES

Earll SR. . Inc . Lat. SRe . Iwcr,

E .rl7 La. Cerr.<t .d ~er r Cerr.ct•d Fer

S02 cow IRE EARLY LhTF SRe. Incr . SR.• Incr . f . .rcl . . Al .,. E .eroie• Al .—

6 C 2.742 4 .566 4 .466 / . 6 0 2 I,627

t-1 4,469 11 .477 • .627 1.66 0 1 .132 1 .96T 6,666

/ .4 l.671 11 .I•J 17 .477 2 .19~ 2 .773 1 .697 2,146

6 .6 2.~92 21 .919 12 .046 12 . 4 24 4.76t 17 .171 a 731

ROK,&C #2 -7 . SCORES

Earl, SRw InCr . La• SR .• Iw<r .

E.rl, La. Cerr«Na t•r C•rr .cbN f .r

S02 COW ME EARLY LATE SR. . Iwcr . SR. . Incr . E. .rcl w Al ., . Eavci•. Al ., .

.6 2.266 2 .627 1 .962 6,161 -4 .1 N

~ .I 1,271 7 .e66 7,419 1.524 1 .264 1 .161 1,444

/ .4 3.261 t .t16 1],921 1 .66/ 1.346 1 .496 l.629

6-6 1.7 44 29,79t N.629 16 .467 16 .764 16 .724 1/ J24

COYeINED ROUOS SR .. SCORES

Earl, SR .. Iwcr . L.t . SR. . Incr .

E .rl, L.t .• C•rr«6.d For Cerr«t-d /•r

S01 CUdC PRE EARLY LATE 5R. . Iwcr .

Sot .

. Iwcr . Eurciee Al ..'. E .-E--. Al . ..

/ .t 2 61/ a .497 7,16e / .1T/ 6.22I

• .2 1.

47

1 9 .62J 6,469 1,442 1.196 1 .664 6.976

• .4 3.366 9,961 13,699 1 .91c 3 .661 1 .646 2.176

/ . 6 1. 0 9 8 29 .769 1677 14 .666 7N 14.27/ 7,617

FEV1 .6 SCORES FOR SUBJECT r1UVBER $7 2

(• wnul/.la •an..a~e - pre .R /3)

ROU~O i3 FEV1 .6 SCORES

F .rl, FEV1 ./ D•cr, Lat• FFV1 .11 D•cr

E .rl, L•t• Ccr •ctd Icr Ccrr .ct•e ~or

$02 COtK RR{ EARLI LATE FEv1 / D .cr, FEVl,/ D.c E,•rc•• Al _ E. .rc .• Alo~ •

9 .6 6 44a 1 310 1 111 9 ele 6.t6 7

/ .2 l.e9e 2 .ue 1 99e R e71 /.ee6 / .e .l -e ee2

6 .4 1 .2e 2-t9e 1 91a 6,766 / .149 • 126 6 ee2

/ .e 1 .I70 2 .666 1,976 t,211 6,00 / 6 19/ 6 el~

ROllO #2 FEY1 .6 SCORES

E+r17 FEV1,0 Dec' . L .t• FEV1 0 D•<r .

11 '17 L.t. Corr.ct•d /ar C. . . . t .4 ~er

$02 CONC ►RE E/~R1.V LATE FEY1.6 Oaer, FEY1 .6 0«r, f+•rei•e Al .- E. .rc ; .• Al,, .

f ./ ! a2e 1 .7N ! 216 9,/76 6 .66 6

/ .t l.761 l .96e 7 .IM / ./ 1{ 6. H6 -6 / 16 -6 911

6 .4 6.166 2 .96 4 2 .916 6.Ka 6./T6 • 619 6 611

6 .6 6.2a/ 3.464 3 .710 6.2a1 /. 1H 5 .7e6 6,169

C06dI7FD RiXlOS F"1 .6 6CORES

E .rl, FEVI .t D«r . L .t• FEyl ./ D«r

E .r17 L.4 C•rrect•e ~er Cerr•<t.d Ier

$02 cow ►RE EARLY LATE FEVl 6 0acr. FfY1 .6 0«r . E .•rc

;

e• Alew. E.erc• .• •le~•

6 .6 3.472 ) .22/ l .212 6/]7 6./6 1

• .! 3,22/ 7,666 l .ea6 6 6U /,966 6/I/ -/_Ie7

6,4 l.266 2,976 2 916 6 164 /,131 e,672 6.666

6 .• 6.2 3 6 2.616 2 . 4 4/ / 226 /,122 6,197 / 061

C-24

R163/ACC W
P- - ~ v~~y

GROUP

SUBJECT N0 . -TL

DATE

~ E- F, F~- z z z

COND. .

SCORING

F- w o w w w - ~ ¢

0. : 11 H , F w U

z cn cn ~ rn x ¢

1=NONE 20=MODERATE F o z c~ E c~ E ~ E '

5=`I`jRACE 30=SEVERE w e.: w cr~ m w cc o G cc

- z E

10=MI L D 4 0=Ii4CAP . ~` '-' x x w x

a w rz w c~ w ~ w c n a .

~± J

CouGH ` I

SPUTUM

SUBSTERNAL SORENESS

OR AWARENES S

SORE THROAT

Y

- I r~

(or HOARSENESS) -7 J ~

SHORTNESS OF BREAT H

NASAL DISCHARGE/

CONGESTION

Ll

WHEEZING

:

CHEST TIGHTNESS /

RESTRICTION

( r ,~

FATIGU E

HEADACH E

FRONTAL : NO YES t

EYE IRRITATIO N

OTHER SYMPTOMS

(LIST)

Lf symptoms & discomfort

lasted several hours,

would they cause you t

(Refer to A- H

A . Decrease o p tional or recreational activity List

B . Take additional medicatio n

C . Be unable to perform the maximum amount of work t 1 at ~rc•.: cculd normally

perform

D . Turn this workload level down(disregar d, fatigue )

E . Be unable to -o erfor^ your usual work* activity or . e _ c` rcductivity

occuaatic n , sc :cc'_-.:ork, critical - . ase^c _ a

F . Stay at ho m e sfck ( '-cse sick time I-= -work

lj . v _~_ - your J .^-~ --

V

C'a ~

_~~ , ~ ._ e :n e_ ^ C ;, _co :c
-75

GROUP

SUBJECT NO .

DATE '1 1 ~4 '~S o

E- H U U

w

H H z z w

z

COND . a F+ ~-

0 3 E- a a

H H w a

H w o w W w H H a

H x a z

Q

SCORING a z m m co

H H H H H H W t_)

1=NONE 20=MODERATE co E' a E5 =T,: RACE 30=SEVERE c; c~ w cn W cn W cr) o r-, c n

10=MILD 4 0=I;4CAP .

W X ~'- x w x w x :_: x °

3 W ~a w cz W ft C7 ~ p

C OUGH

SPUTUM 1 - • ~ L' ~~~ /O /~

SUBSTERNAL SORENESS J v ( ~ /

OR AWARENESS / ~ I I

SORE THROA T

(or HOARSENESS )

SHORTNESS OF BREATH

~ ! r

NASAL DISCHA

CONGESTIO N

RGE/ ~ I

WHEEZING

CHEST TIGHTNESS /

RESTRICTIO N

FATIGUE f I I I l '

i

HEADACH E

FRONTAL : NO YES ~

EY~IRRITATION E

OTHER SYM PTOMS I ( ~

(LIST )

?f symptoms & discomfort

lasted several hours,

would they cause you to :

(Refer to A- H

A . Decrease optional or recreational activity List

B . Take additiorial medication ~

C . Be unable to perform the ma

~

mu'm amount of wor k that ycu Couldormally

perform

D . Turn this workload level down(disregard fatigue )

E . Be unable to perform your usual work* activity or leve l .._ _roducti'rity

occ . r ation, schoolwork, critical household dut 4- e=_ )

F . Stay at ho m e sic,( lose sick time fro m -w o-- -

G . your r n rs :cia :i

E . Visit an

emergency _-cc=
p. 8

~-~:7

GROU P

SUBJECT NO . ) ~l1 J

DATE

E-i H C7 C7

H H z z w

z

H H H H W „ ;

COND . 0 3 H a a

H W O W W W H H a a

SCORING a ~ z CC Cr cc xa~ H H H H H H w ()

1=NONE 20=MODERATE `n F' U

o F c~ F cs F z

5=TIRACE 30=SEVERE w cs: c~ w m w :n w cn o w cn

10=MZLD 40=INCAP . W x '- x W x w x w a rz o

3 x w a w rs w rs ~ a.

1

I

COUGH

SPUTUM

SUBSTERNAL SORENESS I ~ ~

OR AWARENES S

SORE THROA T

( or HOARSENESS) / J I (

SHORTNESS OF BREATH

NASAL DISCHARGE/ ~ I I l

CONGESTION l f ,_

WHEEZING

CHEST TIGHTNESS

N / RESTRICTIO

FATIGUE 0

HEADACH E

FRONTAL : NO YES

EYE IRRITATIO N

OTHER SYMPTOMS l l ~ J

(LIST )

Li symptoms & discomPort ~

lasted several hours, ---- - ., ._. ..._ __. . . . . _

would they cause you to :

(Refer to A- H

A . Decrease optional or recreational activity List

B . Take additional medicatio n

C . Be unable to perform the max i mum amount of work that you could normally

perform

D . Turn this workload level down( di sregard f ati:,'.:e )

E . Be unable to perform your usual work* activity or level of productivity

cccuraticr., schoolwcrk, critical hcuse"no lc duties )

7. . Sta at home s_c's 4 ;lose sick e Ircm

C . Vis'_ oc~ fsicia :

._ c •r 7 ~cm
P

. 9 ~ ~77

GROUP lr

SUBJECT NO .

DATE ~~ ~ il ~ 5 a

H H z z W

CD 0w E r z

COND . a H H H H ca ,~ r

O 3

H W O W W W H H a

N

a

SCORING ~ a z ~ `~ cn H x "

l=NONE 20=MODERATE co

E" ~ E a E, a F

5=T,RACE 30=SEVERE w c~ c7 w cn W co U) o ra M

10=MZLD 40=I GCAP . W x w x w a o

3 w cz w a W ~ w a

COUGH OL

SPUTUM

SUBSTERNAL

OR AWARENESS

SORENES S

J I I I ~ / i

+ J

SORE THROAT

(or HOARSENESS) ~ ~ 1 I

SHORTNESS OF BREATH

NASAL DISCHARGE /

CONGESTION J- ~ I l 1 ~ / V1

-WHEEZING

-77

CHEST TIGHTNESS/

/

RESTRICTIO N

FATIGUE I , J I

HEADACH E

FRONTAL : NO YF.S /

EYE IRRITATION ~ ~ I 1

OTHER SYMPTOM S

(LIST)

?f symptoms & discomfort

lasted several hours,

would the y cause you_ to :

(Refer to A- H

A . Decrease c z tional or recreational activity List

B . Take additional medicatio n

C . Be unable to perform the maximum amount of work that y ou c t uld normally

perform

D . Turn t h is workload level down(disregard faticue )

E . Be unable to perform your usual work* activity or level of productivi t y

(* occura t icr-, schoolwork, critical house h o id cuties )

~~ar at h c =e s -_ _ . .(lose sick .,_We .. m w or.-)

- _ ~ s _ ..~ a n ~ yc

E . a_ S ~„ .".-- e - ^`' - :'oo'^
P.

GROU P

SUBJECT NO .

DATE

~ F- H z z

F H

w

COND .

o 3 E a a

F-i w a

H W o W W W r t-r ¢

SCORING ~

~ z cn cn F- ~n H x < -

1=NONE 20=MODERATE a z

S=ISRACE 30=SEVERE ca gi c w cr~ c~ cc w m o w co

10=MILD liO=INCAP . x w x w x ~ a a o

3 W ~ W CL w ~ W

COUGH

1

SPUTUM

SUBSTERNAL SORENESS ~ ✓ ~~ ~

OR AWARENES S

SORE THROAT

(or HOARSENESS)

SHORTNESS OF BREATH

NASAL DISCHARGE/ + ( j

. / _

CONGESTION I( I

WHEEZING

CHEST TIGHTNESS/ I I

RESTRICTION ~ - 1I l J~

FATIGU E

HEADACH

E FRONTAL : NO YES j I ~ 1 ` ,ll /

EYEY~ IRRITATION f ~ ~ )

OTHER SYMPTOM

S (LIST) i I

Lf symptoms & discomfort

lasted several hours,

Would they cause you to :

(Refer to A- H

A . Decrease optional or recreational activity List

B . Take additional medicatio n

C . Be unable to perform the maximum amoun-7~ of wcrK that you could ^ormall ;;'

perform

D . Tarn this workload level down( disregara : at ig'.:e )

E . Be unable to perform your usual -work* ac ~i-r_ ~y or level of product_vi-„"

cc cup at ion, sc}lcol-.+ork, critical e -

..~ _--e _--__ -- - o Sa at home sick( cse s_

your
P.

GROUP ~

SUBJECT NO .

DATE

E+ H c~ c~ z

H H z z w

CO ND .

H H H E a a

w o w w w H H a ¢

SCORING co co co x

LL . ~ H H H H H H w U

1=NON E 20= M ODERATE CO

E~ ~ H ~ E z o E

S=I~RACL 30=SEVERE w a c~ w CO CO co w m o w rn

10=MILD 40=Ii4CAP . Wx `- x w x w x w a (D

3 w cc w c~ c a c w rz ~ a a

COUG H

SPUTUM

SUBSTERNAL SORENES S

OR AWARENESS /

SORE THROAT / I I ~

( or HOARSENESS)

~

SHORT NESS OF BREATH

NASAL DISCHARGE/

WHEEZIN

CONGESTION

G

_ 9J

CHEST T~GfiT'_4iSS/

RESTRICTION

~ ~ --- -`.

FATIGUE 1 I

HEADACH E

FRONTAL : NO YES J l I '

EYE IRRITATION I I I ~

I

S I OTHER SYMPTOM

(LIST)

Li symptoms & discomfor t

lasted several hours, JrJ~

would they cause you to :

(Refer to A-H )

A . Decrease optional or recreational activity List CA

B . Take additional medicatio n

C . Be unable to perform the Wax ,- -^u= amount c° -work that rou could no r---a"-,v

per_°crm

D . Turn this workload level down(d'sregarc e /

C . Be un able to perform your usual- work* activity or level G : CQllCti'llt;I

Cccu -j atlon, s C :Co 1 '

.7Gc="ltlc2! hc'1se_^_c id G'ltles )

S 'a-; at home s__k( cse s -

pPrs :c i

---

_ :_` a_. e 7- erhe-- r c=
12

GROUP

SUBJECT NO

DATE W

. T

. . [~ - H C7 C.7 z

3

• H H z z t~ ;

COND . H H ~ w

H W O W W W H H w7

O 3

E

SCORING

a cc z cn cr H x

Qr .-^7- H H 1- F•-y H !-~7 U

1=NONE 20=MODERATE co

Sr_' O rz E- ~ E cz E z

5=T,RACE 30=SEVERE w~ c~ w cr w u~ W cc o = cc

10=MILD 4O=INCAP

. W" `~ x w x w x w a o

3 W ~ W ~ W L W G~ ~ C

COUGH l I ~ I 1~ l~ /

SPUTUM ~ I

SUBSTERNAL SORENES S

OR AWARENES S

SORE THROAT ( r , ~ L

(or HOARSENESS) I ! ~_

J

1

j

SHORTNESS OF BREATH

NASAL DISCHARGE /

CONGESTION jo Q ( O ID /

WHEEZING

~ I 1

CHEST TIGHTNESS /

RESTRICTION

FATIGUE I ,

z

HEADACH E

FRONTAL : NO YES

EYE IRRITATIO N 1 ► l f ~

OTHER SYMPTOMS

(LIST )

symptoms & discomfort

lasted several hours, ~ would they cause you to :

(Refer to A- H

A

. Decrease optional or recreational activity List

B . Take additional medicatio n

C . Be unable to perform the max--=um amount of work that you coul m d perfor

D . Turn this workload level down',d'_sregaro `atig'a e

E . Be unable to perform your us u al work* activity or level of ='oduc -1 ='r=y_"

ccc raticn, scaoolwor , c~= ,_ca_ hc',se^o 1r duties )

Stay at home s_ck(icse s_-_, t -_

. 7 _ : a 2 _
13

GROU P

SUBJECT NO .

DATE F H ~ c~

H H z z wz

COND . a ~-+ H

0 3 H H Gz~ a

E- , `a a

H W O W W W H H ~7

SCORING a a z ~ u~ F~ u~ ~ x a z

1=NONE H

a,-~1- H H H H H Cx7

20=MODERATE co E'

S=TRACE 30=SEVERE w c~ ~ w c

Er cEo Co CO oz w E

10=MILD 40=INCAP . W x `- " ~' x w x W o 3 w rx w cc w rz w cz ~ n. p.,

COUGH

SPU

SUBSTERNAL SORENES

T UM

S

I ~ I

OR AWARENESS / I I J ) ` f I I

SORE THROA T

(or HOARSENESS)

SHORTNESS OF BREAT H

l . J

NASAL DISCHARGE/ J r ~

CONGESTIO N

WHEEZING J ~

CHEST TIGHTNESS /

RESTRICTION

FATIGUE

HEADACHE

FRONTAL : NO YES l ' ' I

EYE IRRITATIO N

OTHER SYMPTOMS

(LIST)

If symptoms & discomfor

t lasted several hours, ~

would they cause you to : l C ~

(Refer to A-H _

A . Decrease optional or recreational activity List

3 . Take additiorial medicatio n

C . Be unable to perform the maximum amount of work that you could normally

per for m

D . Turn this workload level down(disregard fatigue )

E . Be unable to perform your usual work * activity or level of productivity

(* occupation, schoolwork, cr'_tical household duties )

F . Stay at home sics~ose sick time _` r- _n wor!S r

your p :. v s1c=a n
\

") U P

SUBJECT N0 .

DATE

COND . z H H H a -~

~3

~ H H Z Z w

c c z

~

0

SCORI N G

H w 0 w w ~ = ¢ <

u= Cn

1=NONE

!1 ~ H H H H H - U C

20=MODERATE x o

X;

5=T'RACE 30=SEVERE

w x F, x w x w x o C

w c~ C) CC a u~ w 011 0 w c~ u

10=MILD 4O=1 VCAP . 3w a w cc w cr w z ~ w a

COUGH

SPUTUM

SUBSTERNAL SORENESS

OR AWARENESS

1 +

SORE THROA T

(or HOARSENESS)

,

SHORTNESS OF BREATH

NASAL DISCHARGE /

CONGESTION I v

i

WHEEZIN G

CHEST TIGHTNESS /

RESTRICTION" I

FATIGU E

HEADACHE I I I I J ~ ~ ~ ' f ~

FRONTAL : NO YES ( I `

EYE IRRITATIO N

OTHER SYMPTOMS ] J I ~ j

(LIST) l 1 I I ( I I t 1 I

symptoms & discomfort

lasted several hours,

would they cause you to :

(Refer to A-H

A . Decrease optional or recreational activity List J~ U S~_

B . Take additional medicatio n

C . Be unable to perform the maximum amount of work that you could normally

perform

D . Turn this workload level down(disregard fatigue )

E . Be unable to perform your usual work* activity or level of productivity

(* occupation, schoolwork, critical househo ld duties )

F• Stay at home sick(lose sick time from work)

G . Visit your physicia n

H . Visit an emergency room
1 5

GROUP

SUBJECT NO

. DATE~ o

F

C4

~ H H z z a

H U 0 z <

COND . ~ H H H H w `

O 3 E- H w o a

w

SCORING ~ a z C° co co x ¢

a =) H H

1=NONE 20=MODERATE CC E

o z rz E ''

5=T;RACE 30=SEVERE w a: c:) w Cl]

- X

W

E

CO

-

w cn c

cc E• z ~

w

10=MILD 4 0=INCAP . w" x w x w

3 w CG W CG W ~ W ~ ._ p _.

COUGH 11~

SPUTUM ~ I ( I ( r

I 4

SUBSTERNAL SORENESS ) i J

OR AWARENES S

SORE THROAT

( or HOARSENESS)

SHORTNESS OF BREATH

NASAL DISCHARGE/ t f ( t ~ ~ I II

CONGESTION ~, 1I I I

WHEEZING

`~ ~ ~/ ~ •~~A /

,

CHEST TIGHTNESS/

~ -)

_

RESTRICTION'

Z

FATIGU E

HEADACHE

FRONTAL : NO YES

EYE IRRITATION I, I ~ I ~ I

OTHER SYMPTOM S

(LIST) I ~ 1

IF Symptoms & discomfort 7

lasted several hours ,

would they cause you to : ~

(Refer to• A- f ~ 'I

A . Decrease ontional or recreational activity List ~ V'1' W i X

B . Take additional medicatio n

C . Be unable to perform the maximum amount of work that you could normal_ ;

perform

D . Turn this workload level do .rn(disregard fatigue')

E . Be unable to perform your usual wor k* activity or level of product :vi- :-

occupation, school w ork, critical househo id duties )

~• Stay at hcme sick(lose sick time f r om Wor~)v

G . Visit your physicia n

H . Visit an emergency room
.16

GROUP

SUBJECT NO .-

,

DATE ~ o y W ~W,

",` c' H U C7 Z

c

COND .

i H H Z z W

o a F a a ~

H W o W W W H H a Q

SCORING x G. ~ H H HH H H W U

1=NONE 20=MODERATE CO E' a ~ ~ E ~ E z v E E

5=RACE 30=SEVERE w cs: c~ w cr~ w cn W cQ o W v~ c

10=MILD 40=INCAP . W~ '- x w x w x w a c~ o

3 W x w cz w c~ w c~ ~ a w

COUGH I I , I f

SPUTUM r ~ ~ J I

SUBSTERNAL SORENES S

OR AWARENESS

SORE THROA T

(or HOARSENESS) I ~ J

SHORTNESS OF BREATH

NASAL DISCHARGE /

CONGESTION (I

WHEEZING

I ~

CHEST TIGHTNESS /

RESTRICTION" t ~ "✓~ ~

FATIGU E

HEADACHE

FRONTAL : NO YES ( l

EYE IRRITATION ~ ~ l I ~ l (

OTHER SYMPTOMS

(LIST) J

I ~ l ~

If symptoms & discomfort

lasted several hours,

would they cause you to :

(Refer to A- $

A . Decrease optional or recreational activity List

B . Take additional medicatio n

C . Be unable to perforW the maximum amount of work that you could normally

perform

D . Turn this workload level down(disregard fatigue )

E . Be unable to perform your usual work * activity or le v e l of productivity

(* occupation, schoolwork, critical househo ld duties )

F . Stay at home sick(lose sick time fro m wcrk)y

G . Visit your physicia n

H . Visit an emergency room
p.17

GROUP V' G

SUBJECT NO .

DATE o w

E H C'

~

L

COND . 0 3 ►d H H

C

HcJ w a ~

H W o W W W H H a ¢

~ a a

SCORING ~ ~ z ~ ~ ~- cn H x a~ H ~ ¢

.{ H H H H e~ - c~

1=NONE 20=MODERATE CC

5=`P~RACL 30=SEVERE w D~ c W ~ G

F

x E~ E7

a

W x

ca co ~ w co

10=MILD ~+O=INCAP . X X W x w a ~ o~

3 w rz w ~ w rt w cc ~ a a

COUGH

SPUTUM l + ~~ i C 1 1 (

SUBSTERNAL SORENES S

OR AWARENESS

SORE THROAT

(or HOARSENESS )

SHORTNESS OF BREATH A f \ ~ J _

NASAL DISCHARGE /

CONGESTION Ip~ I I

WHEEZING

CHEST TIGHTNESS /

RESTRICTION"

FATIGUE

~ ~ 1 I

HEADACH E

FRONTAL : NO YES i l l

EYE IRRITATION I r ~ ( I 1 f ~ ~ ' ~

OTHER SYMPTOMS ~ ~ I I f I ~ 1

(LIST) ` ~ I ) l

Lf symptoms & discomfor t

lasted several hours,

would they cause you to :

(Ref er to A_ EF

A . Decrease optional or recreational activity List ~pMp

B . Take additional medicatio n

C . Be unable to perform the maximum amount of work that you could normally

perform

D . Turn this workload level do v n(disregard fatigue )

E . Be unable to perform your usual work* activity or level of productivit y

(* occupation, school w ork, critical househo id duties )

F . Stay at home sick(lose sick time from work )-

G . Visit your physicia n

H . Visit an emergency room
GROUP

SUBJECT NO .

DATE

r H c~ c~

COND .

/

I 7 0 3 F a ~ H t-~ ~-+ H w ~

H z z w

H w o w w w H ~ _a

(L fL z CI] H H x a

S COgZNG

1=NONE 20=MODERATE E

w ~ H t+ H H H H w U

co M

' ~e o - rz E-4 E-+ cc E- z E-c

5= 7RACE 30=SEVERE w~ v w

w x H w x w x w a

cc w m ca cn o w ~n L

o

10=MILD 40=INCAP .

X C=

3 w cL w r~ w cr w ~ ~ a a

C

SPUTUM I I l ( I y i l

SUBSTERNAL SORENES S

OR AWARENESS ~

SORE THROAT

(or HOARSENESS )

SHORTNESS OF BREATH

NASAL DISCHARGE/

CONGESTION

WHEEZING

C)

CHEST TIGHTNESS /

RESTRICTION' ~l `U J v

FATIGUE I ~ I I I l l

HEADACHE

FRONTAL : iY0 YES ~ I ( I

EYE IRRITATION ~ .

OTHER SYMPTOMS I I I I I l

(LIST) ~ t ! ( l

If symptoms & dzs.comfo .r.t

lasted several hours,

Would they cause you to :~

(Refer to A- $

A . Decrease optional or recreational activity List e~

B . Ta k e additional medicatio n

C . Be unable to perform the maximum amount of work that you could normally

perform

D . Turn this workload level down(disregard fatigue )

E . Be unable to perform your usual work* activity or level of productivit y

(* occupation, schoolwork., critical househo 1d duties )

` . Stay at home sick(lose sick time fro m

G . V_si -. your physicia n

H . Visit an emergency room
GiROUP

SUBJECT NO .

DATE o w c

~ E+ H C7 U z

H H Z Z W

COND . H H ~+ H w a ~

«-+ w o w w w H H a a_ `

O 3 E-i a a

CG C~ Z m CA co 7C

SCORING ,..,, w U

l=NONE 20=MODERATE

~e

o a E- ~

Ea

5=`PjR ACE 30=SEVERE wct-. v w CO w co c c o w cn ="

10=MILD tiO=INCAP .

W x `-' x w X w x w a cc o c

a w X- w cz w x w a ~ a a

COUGH

SPUTUM

~

SUBSTERNAL SORENES S

OR AWARENESS 1I

SORE THROA T

(or HOARSENESS) ~ I I l

SHORTNESS OF BREATH

jz

NASAL DISCHARGE /

CONGESTION I I I

WHEEZING I ~ I ) ( I , I I

CHEST TIGHTNESS /

RESTRICTION

FATIGUE ~ ~ I I I I I , 1 (

HEADACHE ~ ~ I 1 I l ~ I

FRONTAL : NO YES ( I I

EYE IRRITATION I ` I I I (

OTHER SYMPTOMS / ~ 1 I f I

(LIST) ((( l /

Lf symptoms & dzscomPqr.t

lasted several hour 5,

would they cause you to : /-1

(Refer to A-H )

A . Decrease optional or recreational activity List

B . Take additional medication .

C . Be unable to perform the maximum amount of work that you could normally

perform

D . Turn this workload level down(disregard fatigue )

E . Be unable to perform your usual work* activity or level of productivity

(* occupation, schoolwork, critical househo 1d duties )

F . Stay at home s-cls(lose sick tire from uc~y)

G . Visit your physicia n

H . Visit an emergency room
GROUP

SUBJECT NO .

DATE

E 1- C7 c7 z

C O N D .

0 3 E

' 1 H w o w w w f-+ H a _

H x a z

SCORING

tz z `n co M

a~ ~ ~ a - ~, H ~ w c

1=NONE 20=MODERATE E- U E

5=`~}ACE 30=SEVERE w Ew cEc w co cEn o w c~n U

10=MILD 4 0=INCAP . w X r' >` w x w x w a o

w a w rz w ~ w a a a

C

.

COUGH

SPUTUM lC~~~ l ~ I I 1 I I l I

L

SUBSTERNAL SORENES S

OR AWARENESS c I I ~ ` I ( ( IC

SORE THROAT r ~ ~ I ) { ~

(or HOARSENESS) r l 1 I I

SHORTNESS OF BREATH ~ ~ I ! ! I (

NASAL DISCHARGE/ I ~ ` (

CONGESTION ~ 1 f I I

-XF.EZiiV G

(CII5T, J

FATIGUE

~

HEADACHE

FRONTAL : NO YES

EYE IRRITATION

OTHER SYMPTOMS

(LIST )

If symptoms & dis-comPor .t

lasted several hour a ,

w ould they cause you to :

(Refer to A-$

A . Decrease optional or recreaticnal activity L f 6-tB . Take additional medicatio n

C . Be unable to perform the maximum amount of work that you could normally

perform

D . Turn this w orkload level down(disregard fatigue )

E . Be unable to perform your usual work* activity or level of productivity

(* occupation, schoolwork, critical househo ld duties) r

F . Stay at home sick(lose sick time from wcr'-k )y

G . Visi~ your physicia n

H . Visit an emergency room /~
21

GROU P

SUBJECT NO .

DATE

E '' - - - --- _.

COND .

- 0 3 w a

'- z z w

w o w E a =

w w a a

`

SCORING a ~ z H H m H cn x ¢ - -

1=NONE 20=MODERATE o F'

E- E E Z U ~ e

5=`I~RACE 30=SEVERE w~ cf] w

CO o w ~ c

10=MILD 4 O=INCAP .

X x x w ~ o c

3 w cz w rz w ~ w cc a n

COUGH I I J ~ f I ~ I ~ `

I I I

SPUTUM ~ ~ i ~ I I 1 I I i ~ I

SUBSTERNAL SORENESS I + `

OR AWARENESS .

SORE THROAT

(or HOARSENESS)

SHORTNESS OF BREATH

NASAL DISCHARGE/

CONGESTION

WHEEZIN G

CHEST TIGHTNESS /

RESTRICTION" I I ~ •-~ !~ ~ '~ :

FATIGiJE 1 I ! 1 I I I ~ I ~ ~

HEADACHE

FRONTAL : NO YES J I

EiE IRRITATIO N

OTHER SYMPTOMS

(LIST)

f Symptcros & discomfort

lasted several hours ,

would they cause you to : rJ r N ,~Ui

(Refer to A-~ )

A . Decrease optional or recreational activity List

B . Take additional medicatio n

C . Be unable to perform the maximum amount of -work that you could normally

perform

D . Turn this workload level down(d ;sregard fatigue )

E• Be unable to perform your usual work* activity or level of productivit ;,r

(* occupation,'schoolWork, critical house'--c Id du -I ies ) F . Stay at home s_ck(lose sick time from

G . Visi~ your physicia n

H . Visit an emergency room
,OUP.

SUBJECT NO .

DATE Jv o w

E' ~--~ c7 ~ z z

w c~ oW

COND . !~ H H H H W a a

H ~-+ z z w

w o

w o w w w , H a a a a

a

¢¢

.SCORING x x z v' CO x ¢ = =

1=NONE 20=MODERATE x o F' a E ~ E ~ z ~ ~ H o

5=T'RACE 30=SEVERE w r~ o w u~ w ~ w o cn ,

10=MILD liO=INCAP . W x H x w x w x w a cz o o a

a w cc w rz w rz w cc ~ a w a~

COUGH ' h I ' ~ I 1 I

J L

`

/

SPUTUM

SUBSTERNAL f I i i (I ~ ~ ~ i

SORE THROA T

(or HOARSENESS)

~

SHORTNESS OF BREATH 1 ~ ~ I I ~ ( I I ~

NASAL DISCHARGE/

CONGESTION

WHEEZIN G

CHEST TIGHTNESS/

RESTRICTION

FATIGU E

HEADACHE

FRONTAL : NO L ' YES

EYE IRRITATION

OTHER SYMPTOMS

(LIST )

If symptoms & discomfort "I' G

lasted several hours ,

would they cause you to :

(Refer to A- H

A . Decrease optional or recreational activity List

B . Take additional medicatio n

C . Be unable to per°orm the maximum amount of work that You could normally

perform

D . Turn this workload leve l down(disregard fatigue )

E . Be unable to perform your usual work* activity or level of productivity

(* occupation, schoolwor k , critical househo id duties )

F . Stay at home sick(lose sick time from work)

G . Visit your physicia n

H . Visit an emergency room
LGROU P

SUBJECT NO .-"I ( ~ i

w

DATE 0

E H C7 C7 Z w

H H Z z G]

COND . ~

H H H H W a -~

0 0 H w w w w H H a ¢ d

e+ a a a

fL (L z U] CA H C!~ H x ¢ .SCORING (l. ~ N H H H H N W Y U U

l=NONE 20=MODERATE co ~ ~' o U c~ om

5=T~RACE 30=SEVERE w~ w M w ~ w m oz W co MN H

10=MILD 4 0=INCAP .

W

a w rz w rz w cz w ~ ~ a a a

x x x x w a c~ o o a

co

COUGH

SPUTUM

SUBSTERNAL

SORE THROAT I

(or HOARSENESS) I J ~ j 1 ~ J ' 1 ~D f

SHORTNESS OF BREATH I r~ ~ n

NASAL DISCHARGE/

16,

1

v ~5 J

~ ' ~ ~ O lO ~~ C O ~

CONGESTIO N

WHEEZING

CHEST TIGHTNESS/

tv CW J0

`6 b

RESTRICTION 1 V

FATIGU E

HEADACH E

FRONTAL : NO YES

EYE IRRITATION I I I I ~ r ~ ~( I

OTHER SYMPTOMS

(LIST )

symptoms & discomfort A' A 74-C, C 4C

iasted several hours, ~~

would they cause you to : ` Z

(Refer to A- H

A . Decrease ootional or recreational activity List d,zlf , i a

B . Take additional medication

C . Be unable to perform the maximum amount of work that you could normally

perform

D . Turn this workload level down(disregard fatigue )

E, Be unable to perform your usual work* activity or level of productivity

(* occupation, schoolwork, critical househo ld duties )

F . Stay at home sick(lose sick time from uork)V

G . Visit your physicia n

H . Visit an emergency room
2

GRjUP • _ ,

~ ./~

SUBJECT NO . J I

DATE o w c~

~ H r+ z a w

E- ~, o c~ z z

w

COND .

~ '~ r' ~+ N w a a

0 E-4 a a a

F-+ w o w w w ~ ~-4

SCORING

= a:

z

M C0 M `-+ x

a= r+ -, r, ~ r a r+ w - U U

1=NONE 20=MODERATE co 0 C ~e o ~ x E- E- X E- 1 z E E- a

5='i'iRACE 30=SEVERE w a: w co w co w co o w co co

10=MILD 4O=INCAP . W x ~, x w x w x w a ~ o o

~ w a: w a: w z w cz = a a v

COUGH C)

SPUTUM I I ~ ✓ 1 ~

SUBSTERNA

L SORE THROAT

(or- HOARSENESS ) ~ I I I I f I I J ~

SHORTNESS OF BREATH

NASAL DISCHARGE /

CONGESTION r I 1 1 I

WHEEZING I ~r I ~ l I J ~ I~

CHEST TIGHTNESS /

RESTRICTION f J .l J [

FATIGUE ~ ~ ~ 1 I r I I I I ( I ~

HEADACHE ~ ~ I f 1 I / ' I Il

FRONTAL : NO YES

EYE IRRITATIO N 1 I !~ I ; ~ 1 1 l~1

OTHER SYMPTOMS

(LIST) f ~ ! !

If symptoms & dis-comfQr.t , Q

- -- --- lasted several hours, ,

would they cause you to :

(Refer to A- H

A . Decrease ootional or recreational activity L'_st jo'F

B . Take additional medicatio n

C . Be unable to perform the maximum amount of work that you could normally

perform

D . Turn this workload level down(disregard fatigue )

H . Be unable to perform your usual work* activity or level of productivity

(* occupation, schoolwork, critical househo ld duties )

F . Stay at home sick(lose sick time from work)v

v . Vi.sit your physicia n

H . Visit an emergency room
p•

SUBJECT N0 . Ul -

DATE

~ H H Z

[,4 !~' \ 0

E+ H c~ c~ z z

z

COND . a

o N a a ¢

H H H H W a a

H w o w w w

LL' a+ H a

H

Z

U~ H H H H H W U

U] H U~ H Q

SCORING (1. a H X U

1=NONE 20=MODERATE U2

5e o E E' . rz E+ cc E• z E4 a

5 #T~RACE 30=SEVERE w a : c~ w m W cn W co o w m M

10=MILD 40=INCAP . W x w X X a rz o oa

3 W rz w cc w x W cc ~ a a. a. cr.

COUGH

SPUTUM

SUBSTERNAL SORENESS

OR AWARENES S 1 C/

SORE THROAT

( or HOARSENESS )

SHORTNESS OF BREATH I 5 I 5 ~ ~ I ~ ~

NASAL DISCHARGE /

CONGESTION

WHEEZIN

G CHEST TIGHTNESS/

RESTRICTION

FATIGUE J I ~ \ 1 ' ~

HEADACHE ~ I I ~ I i I / l (~

FRONTAL : NO YES

EYE IRRITATION `

OTHER SYMPTOMS I I ( ( 1 J J I )

(LIST) ~ } I I

If symptoms & dzs-comf pr.t

lasted several hours.,

would the y cause you to :

(Refer to A- H

A . Decrease optional or recreational activity List

B . Take additional medicatio n

C . Be unable to perform the maximum amount of work that you could normally

perform

D . Turn this workload level down(disregard fatigue )

E . Be unable to perform your usual work * activity or level of productivity

(* occupation, schoolwork, critical househo ld duties )

F . Stay at home sick(lose sick time from 'wor k )v

G . Visit your physicia n

H . Visit an emergency room
p~,

GROU P

SUBJECT NO .

DATE ° w E• H `' 0

U U z

~ l H H z z w

COND . ✓~

~' H H H H W a

o s N a a ¢

a

H w o w w w H N a ¢

a rz z m :n H m H x ¢ ~ z

-SCORING (L ~ H H H H H H W U U

1=NONE 20=MODERATE ~e o rs F F cz F z ~ E c~ M E'

5=T~RACE 30=SEVERE w is; 0 w co W co w cn o w cn ~''

10=MILD 40 -IlYCAP . a W x w x x x w a rs 0 o P .x W x w rz w c~ w a a cn

COUGH

SPUTUM

SUBSTERNAL SORENESS

I x

I f ~

OR AWARENESS "

0

SORE THROAT

(or HOARSENESS)

SHORTNESS OF BREATH

NASAL DISCHARGE/

CONGESTION

WHEEZING

CHEST TIGHTNESS/ ( i I ~ ~ r

RESTRICTION ! I J I ~ ;~ ~~ !

rATT_GU E

HEADACHE ~ i ' ~ J l I j (

FRONTAL : NO V/ YES

~ I I 1

EYE IRRITATIO N

OTHER SYMPTOMS

(LIST) 1 1

?f symptoms & dis-comfort

lasted several hours ,

would they, cause }^ou to :

(Refer to A- H

A . Decrease optional or recreational activity List

B . Take additional medicatio n

C . Be unable to perform the maximum amount of work that you could normally

perform

D . Turn this workload level down(disregard fatigue )

E . Be unable to perform your usual work* activity or level of productivity

(* occupation ., schoolwork, critical househo Id duties )

F . Stay at home sick(lose sick time from wor k )v

G . Visi7 your physicia n

H . Visit an emergency r oom
p. 27

125

SUBJECT NO .

DATE I~~f '~,1 o w ~ z

E' H c~ ca z

H H y y [z]

w

a

COND .

a H H H H W ,. .a a

o ~

H w o w w w H H a ¢ _

E-4 .~ a a

-SCORING w a z ~i H H H H H w 4 U U

1=NONE 20=MODERATE co F' v

E-4 a

5~25RACE 30=SEVERE ~ w m w co w cEoz w o cEo U2

10=MI ~D 40=INCAP . 3 w x w rws w w a a a

a

Cr.

COUGH f o O I v l ~ I(~ 10 Z6

SPUTUM -to L) f

SUBSTERNAL SORENESS

OR AWARENES S

SORE THROA T

(or- HOARSENESS) 1 i

SHORTNESS OF BREATH J-0 10 ID 30 )0 / 0

NASAL DISCHARGE/ /~

CONGESTION ao 1 CJ (~ 16 / 0

WHEEZING I I I ~ J' ~ ~ / O J

CHEST TIGHTNESS/ /0

RESTRICTION ~ZO ~ U ~U ~O 3 0 ~

FATIGUE 1 1 I ~ I ~ ~ ( I / ~ ~

HEADACH E

FRONTAL : NO YES (~ I J (

EYE IRRITATION

OTHER SYMPTOMS ? O I ~ ~ ' j J J

?f symptoms & dzs-comfpr .t `~I ,J G Q

lasted several hours, Ft~

would they cause you to :

(Refer to A- H

A . Decrease optional or recreational activity List

B . Take additional medication ~

C . Be unable to perform the maximum amount of work that You could normally

perform

D . Turn this workload level down(disregard fatigue )

Be unable to perform your usual work* activity or level of productivity

(* occupation, schoolwork, critical househo ld duties )

F . Stay at home sick(lose sick time from wo•-k)v

G . Visit your physicia n

H . Visit an emergency room
. 28 -

GROU ?

SUBJECT NO .

DATE 0

~' H H z z w

E-4 -+ U U z z

a

COND . A H H H H W a a

0 a H a a ¢

H W 0 w W W H H a ¢

.SCORING

CG p'-. z m H U] H ¢ m x

a a H H H H H H w ~ CJ U

1=NONE 20=MODERATE Se 0 + ~ E• G

co c

. rz [~ z E a:

5=TRACE 30=SEVERE a: ~ w u~ w m w m 0 w m

10=MILD 40 =INCAP . W x r' x w x x w a ~ 0 0 aa w c~ w rz w ~ w a ~ a a a U

COUGH

SPUTUM ~ !D ~~~ l 0 IC 1 c' IC'

SUBSTERNAL SORENES S

OR AWARENESS

SORE THROA T

(or HOARSENESS) I 1

SHORTNESS OF BREATH

NASAL DISCHARGE /

CONGESTION ~~ ✓~~ ~ ~ ~ Cj ~ ~ ~(~' ~ l~" ~~ ~Cl 1 ` (~l

WHEEZING I j ~ ~ I I 1 (+ ~ ~

CHEST TIGHTNESS /

RESTRICTION C)

FATIGU E

HEADACHE I~

FRONTAL : NO YES T

EYE IRRITATION ~ 1 !' ~ 1~ i l I i

OTHE R ~ ~ I I I r I ~ 1 I 1

(

SYMPTOMS

LIST' J ~

Lf symptoms& dis-comPQr .t

lasted several hours,

Would they cause you to :

(Refer to A- $

A . Decrease optional or recreational activity List

B ,, . Take additional medicatio n

C . Be unable to perform the maximum amount of -work that you could normal_y~

perform

D . Turn this workload level down(disregard fatigue )

E . Be unable to perform your usual work* activity or level of productivity

( * occupation, schoolwork, critical househo 1d duties )

F . Stay at home sick(lose sick time from work )V

G . V'-sit your physic i a n

H . Visit an emergency room
, .

SUBJECT

o

DATE 6 H H~ ~ z z

1 H H z [z] W

COND . ~ H H H H W a a

O 3

H w 0 w w w H H -a ¢

cccc z Cl) Cl) H C1) H x ¢

- SCORING a a H H H H H H W U U

=NE 20=MODERATE Cf) F' 1NO SC o - rz

0 E, a

5`I;RACE 30=SEVERE rs: c7 w

C_

W w n w

Cr

co 0

E-4 z E

w co co

10=MILD 4 0=INCAP .

W x H x w x a x w a X 0

3 W a W ~ w ~ W CG ~ a a

C O UG H o / 0 ' ~ ~ ~CJ J

SPUTUM l D ! D l v l l~ ~~ D ~/ J~ ~ ~V ~D

SUBSTERNAL SORENES S

OR AWARE NESS ( ( (

SORE THROAT

(or HOARSENESS) )0 16 5,

SHORTNESS OF BREATH

NASAL DI S

CONGESTIONHARGE/ 0 10 10 0 10 20 -Z -20

rD

~2

WHEEZING ( 1 / ~ 1 ~ I J l I l 1

CHEST TIGHTNESS /

RESTRICTION

FATIGUE

HEADACH E

FRONT I L : NO YES

EYE IRRITATION

OTHER SYMPTOMS

(LIST )

=f symptoms & discomPpr .t A

asted several hours ,

vould they cause you to :

(Refer to A- H

A . Decrease optional or recreational activity list O~~rC~Se

~

ItLaff

B . Take additional medicatio n

C . Be unable to perform the maximum amount of work that you could normally

perform

D . Turn this -w orkload level down(disregard fatigue )

..~ Be unable to perform your usual work* activi -~ y or level of productivity

(* occupation, schoolwork, critical househo id duties )

F . Stay at home sick(lose sick time from work )V

G . Vi.sit your phys_cia :

H . Visit an emergency room
p. 30

Zd

T) - - - = - =

~ C H

,'O Li~ = 0 '~7 -~ E G:

--

== 7D c~ -,O=--

^- - • " -- -' ,-C .- .~C "" 0' ^ IL o = - 'y C

it

0 U G _ ~ ~ I ! ~~ 1 1 I ~~ 1

Jm U%Lf I I J ~ I ~ { J ) ~ I I

J3 Sr'EaNn_ -~,, S~~ `_. ;4T~S J

~~ o! ^

~- r OA 5 7,N E33) I ~ ~ ~ ! ( 1 I 1 1

OftSS 0= 3~ ^_

T .

c~~

.,

T C

R C - o -Iv 1 I I ~~ ~ ~ i I

_._ Gu-

~

DAC-:-

~' .,T^^-L : Vo ~ S f

_ s~-rer~1 hou :s ,

i,a°,r cause vou

" O !k -3 )

Decrease OD t lO n z l or *•°Cr _° L_0I72__ ?C t 1'ri z- '_~ Lis-,

m2 :i e ZQQ 'z 1oClz l m °Q :.C? t lO Q

3e unable to D ~2 : O r S t ,1 ? m ? :C 1 m ll'a amount of O r _ ; t 1 a- you Could n O *_• .: z ll V

D er :ora

u :-a this c:orklOZd 1~~,rCl QOr.rntQ=sr°~garQ L?

3c' uClZOi° to D?' 7 - OtS your Jd~1C llsilz l 3Ct i'r~_ z f or 1°,r°1 of or

OCC'1D Zz? O ❑ , 3C•700i-~JOrK, C : 'I QOUS ~^O ~ Q 11 L

.. .. ay- at Cl O Q: L o s e se s _ C = :-oar

f- 5_ o ll- O C : ~

j_~__ _ .

. --•-- --- D . . .
p.31

. _-_-_ ~~ ~~ " ~ ~ ✓ ~~~ ~~ ~

/ / • i. ~✓~ L r .

r 1

L=

~a=z =7=-=

? 0='S__ .

-- _ - - = - = _ _- c

C ~:`_ ! I ~

~

~__-_~.~_~ ~- _-_~__ ( ~ i f ! ~ ~ 1 ~ ? ~ ~ ~ ~ ~~ I 1~ ( , , ! ~ ► ~ ~ ►

G _,=,~~ f2CI zd

C

-~

: .ti___~= ~,f~ {~ ~r~~{ ► f, ~fl~~,~ ;

~ .~ --:=--~-=~~~Y { ► , ~ { 1 { ~ ~ ( ~ } ~ l ~ ( ~ f 1 f ~ f ~ ~~__,~ I ! { I I

IQ3 :~'^ ^S ~ . _-?? QCtS' a

4 _

C_JCtI C

.- :T 1

. J

----

~ Borg FYe_an Sc~ e

Rerz to 0-10 J 4 ) ~ ~ ~ ~

_ . I 1 I i

A, Oc=-__sa a~c?ar.=! a .-

6 . Ti'__ zd¢ '_aaa! c_c :czc'_c a

C . 3a un_c! _ to o= -°~_ ~c - -

a,=ou.a o : 'roct cC¢_2 no :=z11 r

_•- C :~-_

61i5 _=0 _s

ti, ;,

~., ~ ~ r
p

. 32 ~ Oc

DA m-

C

COND .

C) '-: ~-- .

<

S l. O p ! V G CO H CO H yG ~ ~ .~

1=NONE 20='~rODE :?^mE v cn ~ v ~ c~.i

5=TRACE 30=SrVF.RE ~ CO CO f_i o C-- E--

1 = ;.fTT ~ X H X Ci ;C >< ~ G^.

0 ~D 0- `v C?__ C--

a c° c. ^ :

~0UG 3

3 RUTU M

S 17B S?'ERN4 L SORENESS

t±_ ±

)R 'SJ

S ORE TRRO

-

4 7

. or HOARSENESS )

:cORT N ESS OF BREATH Is 1 5

'A S, , D TSC rn_ RGE /

ONGESTTON 1

0

Id ! 0 1(~ 10

aEE Z .v G

HEST TTGn^'_1 -" SS /

E STR TC'nl0iv `✓~ !( `✓1

-_~ TCIUE 1,j 1 () 10 ZC~ 10 l~ IC~ lU

EADACLLE 1515 5-15 S ~ ONTnL : NO Y YaS 1 5-1

`E IRRITATIO N

L'HER SYMPTOMS

(LIST)

ymotoms & discom*orT

ed several hours ,

d they cause you to :

e Y lyi o Q - F /

Dec r e a se ootional or recre a tional act i vit-~ List

Take additional medic a tio n

Be unable to perform the maximum amount of o~ jc that you could normally

perfor m

Turn t :1'_s wCrlC l oa d l P1le l Qot; ; ( a'_sre~,:: CI i ? z _

~g ue )

Be unable to re'_"Io rm your usual work' aCti'I ' ty or l o ,r ol of croQucL1`%1 z .1

~ l ocC 1 r 2 t i oCl , sc hool ::o r'~c, C_' : tiC al household duties )

Stay at (1C^_ S i cL; ( lose S ;_C`: .,_ :l'' from

'~ i t }~JL_ Df7_'S _C _a . . ~

V 4- s : ., a . . enC'f 7 ~om
p. 33

Qv S

.

~

c

~ C ~vT i7

- r-- -_-

= = - `-- _ -_

c

? = .aov1 20=_0 DE_R ^_^ r_ cr C-) C-) =

i=-°yC 3 0=jCY~ G7 = CJI U cn L v, i. D L 0= N C

A ?

. x s yc :_. c

7 :

,OUC H

U q.liu ~ ~>> J~ 1 J I ~ I

v IB S TEa :v^-_ :, So ID =,V E SS I !

R a .y~~~~~S s

C HE (?C~ n n

or H o"_R SL ;`rL.S S

EOR"-''YE SJ Or 3 LD =^ -q } , I ~ ~ ) ! ~ I

^_Sa D~SC12rE j

,~ ► -

s

-

~mr~ ;

N ES S _

-_ C ~~

o NT ~~J NO YJS ~ x j 10 /0 o<< J c~ ► ~ c~ ~ c~ t ~ 1~

( r. ~ m 1 kn ec ~ lJ ~ 1 I v lJ S ~~0 1 1( 5 f

~scc ;~_~~ .-

5°7~ 7 3 l hours

za ° :1' r°15` d0u i,o=

O A - H

Jec - _ _~s e o Dz ioczl or r e cre a n a ~c _ 7 _ Z _rti-f s

'GG= Z ion al m e'i ca z !O n

~e unab to De_ or~ th e Z rou cou "

oerior m

T 11 r n t _ ' - S -w o r ' ~ i o 8. d L Z V e 1 Q O c. :( Q' S r " !zc. - 3

,

e ll r_

Oc

"

c

, L to

O(1

D e _ = 0 T' il

s c `l00 L

VC

.:Or_

l2 = u 5 -

7

c C C

- . .

T ` r

L o e c

• _ S _
p. 34

- = _

~

C_ ~ - - QND . - - _ -

GPP

,1C- >C

_

_

E .- -

i_?a0v~ 2~JDL_A-_^ E v rr, - ~ C-)

- _`~ n-C ,r 30 -J..V E i i CC _

cn ~

X F X cc J t cr) co

0-'X T T .J L 0==~ 0~~' ~ ^ X X ~' w ~ ~ c

- ~•_ : ~ ~._: (~ ~. ~`-. .~ -

H;_

~(Jmr;m

o2S LE°_vn-_:', SO IDE N:SJ

vrJ mL'~On_ m

or fi0 ~-'S E RrESS,

_Ot?"_v:SS . OF 3? 7

n_

D TC C :,d?GE I

3 N -C- r. S '" ' O

- S

7- El Z

T 7 _ e -Z T

1 I ~

S^C" ! 0_v l

T T C: J ~

A~

A C H

OYTn-LJ N

0 77a S v-Xj''O M S

~ T, = -

. "' ! ^

1 ~ .w.~ ~j 30 ~ ' ~J ✓ I'

-czoas & aiscom_orc

d seva--al aou : s

tae,r c2-use vou

' z o ?. a )

L7eC 7 e3s e optional or r

2 1C ;? ' ? C

"a'~e additional ^j e d '_ca z :o n

3e unable to oer'orm the Ma .ci u m a~cus : t:~z sou could no=a==~r

oe :- ror:a

`='u_- .7 this -%or~-I o2Q QO

Be unable to D e '_'=o r -m v our usL' a ' 0 : 2C 7_` O~ ~ r~l p i DrCQL'C _r

CZ ~00_ .

:0, ----' > > yll ~ _ __ ~

v ~~-

'~
35

p

.

CO N D .

SCOR! VG

G R P r = c_ G= ~~ •= CC Co

r ; H r. x ¢ C -

1_`?OY E 20= M OD E

RA T .L

Q E- 0 Ei

C-)

5 =T- R A C 30=Sr.VEni c c ~ co z E- c

10=uT~,D L0= VC ~° . x

U? o M u

-

a, c

a. ~.,

: OUG H

7 ?UTU M I T

7 URSTRRIIAL SORENES S

) R AWARENES S

: ORE TLRO~T

LL or HOARSENESS ) I ► 1 1~' `~ ~ S- S`~

HOR`"ivE SS OR BR R1`- F i t l l ~ ~ )

A SAL DISCHARGE /

ONGr.STIO N

HEEZ LvG

HEST TIG H TNESS/ ~ ~ 1 1 1 ~ ~ ~ i ) 1

~STR_C`"IO V

^~

`~ J ~- ~

_' ,_ DAC II E

;ONTiL : NO YES

'S IRRITA TION

3". 'R S l[!vfPT ~~ ~

( LIST C ~

, ~toms & aiscom_o .-

e

i

d several

they cause you to

hours,

:

~--~ - -- -- -

-2 ,- to A-3 )

Dec-ease ontionzl or recreational a ctivitv List

Take additional medicatio n

Be unable to perfor m the m a .c_ m ur~ a m ount of ~orti that you cou_d r.or~all .f

nerior ~

Turn this workload letrel do v n(dis_ eg-a rd :a t :=ue )

Be unable to ner :or m your usual acti•r ; t,r or le,,-el of cduc _'r=

P- oc cuD2 t ion , sc h Oo'~'.:O rtC, c _ - ., i _' l _r~ous e .^o 1Q Qll ~ 1 °s )

Stay at home s .. cH =

J_s_ .. your ofl_r s _ c _ an,

~' ~ ~ _ ~ _1 ._ -C,D Cl
p. 36

n

~_,J C7

,

01 v ~ c ~- l^ r^ _ `

_

v ~

' ~iC 7C

F- r F-- -

l= jO m 2~=-- :D-?_`- T- E

5=TRACE 3 O= 3 G T! E _ . E

10=111D Lo=__~rC AP 0 X ;<

CO r

~ PU = U u > > I ~ i

Su3 2 T z'R as,- SORENES S

OR AT __ RE_'d E ti S

SORE THROA T

( o ; HopaS E :r Z SS ) ( ~ 1

S _CE .,,rEs S OF S~`--- -- ~ r

W -~~~ IU G

_v_ ! _CnTo ~,r E SS I

-'-`=== VE c 1 ~ . 11 ~

HEADACH E

:

R O W _-_L : VO YES

EYE ; RR s TA m ION

m- J_~i~J

`

SYMPTOMS

~ ! ( ~ ~ ~ • ~ ~ -

s I=^ t o m s & Q1sc c :1_0 r .-

t Z^ several hours,

id they cause you to :

fer to s-3 )

Decrease ootionh or recreational activity List

Take additional melicatio n

Be unable to perform the ca uiyum a mount of ::or k t :l ai you ccu L c normally

perform

T u r :, t h is w or k load level do wn (disre g ?r d fatigue )

B e unable to perform your usual vor_'.{ activity or level of r o QUcCl`r'_t .r

( ' Occupation, scsloo Lv o r . c _''_ o 1c3 l (lous e ^o ld duties )

c z a7 at home s _ _ . t j o s _ s j7. . .-. .

V - = - t your - y

' - - - -

V - S -_ - ._ °--- -. . . r __ . .
- - - • . i p; 37--,, '

D

_, _ ;~~~ ~ 4~ ~ r' ~.'~~~'~ ~'> ~ , ~-~ , u~,~ ~ • ~~ ; ~

r • = - -_ ~_ ~ CC\D

SCO R -

~

:~T C

O = ^

~ = .; 0 V _". 20 - _1,f O D i, 7 rt T

U: U - ~' ~`

. --+ . ,_

. •--_ U

O

5 _ H _A--CL 30=Sc V 7- R ~

10='r LO ~OIVC?° . = x X

? CrI

_.

1

COUG H

J~JTU M

E U3ST E 3N A,, SORENESS

OR AWARENES S

SORE T EH O_^-_'I' ~

(or HOARSENESS) 1 ~ ~ ~ I

/ ~ r 1

--= O D T V°. .C.J O "

`i-^--s L DISC. : _ P

0?ve E S T _p N G - ~ ) ~ ► ' I ~ 1 i )

~~

C HI

~ST~ CTTpV i ! f

EE 7- 7-

ST T=G~

I~: G

;TN EQ S /

I ~ ~ +

! l l 1 i 1 ) I

AD pC HI E

'~OYT A -T : V0\

`! 7S

I R RITA TION

) T EHER S r XPT p M S

( D 1 J T~ 1 I

S ymotoms & di=ccra_o . - 0

g C

~

-ea sever a1 oou~-s , ~ - - 1 1 j

they cause y ou t o

d

-°_r to A - T )

-~ Dec-ease oDL 1on al or recreational aC t 1v1i, r !,_ j

Take additional m-2dicat,'Orl

Be unable to Der--Or= the maximum amount o f work t,-Ia-- you could normally

perfor m

Tura t ;iis workload >>_ ,re1 dovn(disre g ard i az i s ue)

Be unable to perform vour usual wor'tc' ac t i-r~ ;,f or of D roauct.i vi-I

( s occupation, sC _^oo -w o r`C , critical !'ious e^o ! 1 dll z 1°_s )

Stay-at home s : _ r; lose S'_ C~; from -=o>' ~)•J

V_s_ z~ Your _rs------

Y-~ Dc,-
^

- -~

-

X

1=`0'd 2 9

=,_

_ _-- v U U C' Sr~ J C r C '

= '7-H 1_Cl. 3 Q

_ S G 'J

~" L'~ _*7 "

0

_' =~ • : r--

' U (-_'t U] r_- = - C

10=',rrr, D L0=! :1C ,~° . U] u7 O C G~ - CQ

CO U G H

SpUT um IT I

JU3S T=. R !11i, S7~ :f S J

0 R A ;Y An P t'V :.`l'J

1 I I I, I ~ ~I ~

ORE THROA T j S

(or HOARSENESS )

3 H 3S 0? ~?G?_

R / ~ ( I 1 I / ~ I / ~ I

HA S :?L D 1 SO~

-

CI/ I

~ ovCEST_o~;

HE E ZIidG

SS~IC

m

TIGHTNESS /

~' 1 `r' '_ C iJ G

F(O ~ ✓

EnD 15 CIIE

S

0NTA L : NO v

I ) / ~

:Y E IRRITATION ~.~ , ~ l ~ r ( ! ( ~

`!'HER SY M ?^OM S

>yriotoms & disccra :o : .z

ed se v er a l hours ,

_d tae y c a use vou to : -` -'--- __

°r to 1-d )

Decrease optional

or r ~

~ e~ .e=tional activity L ; s t

Take additional medicatio n

3e unable to oer=orm the maximum amount o f ::or ., that you could normally

perform

Turn this vor!cload le v el doun(disregard iati g ue )

e unaD le

to Perform your usua l T.rOr~:l ac t l'Iii.f Or Level of DrOauctlvl t ;j

OCC1Da :0i, school-

.:0 : lkc , critical ClOus e^O id duties )

;Y '-~ no ..,_ s__-( j os_ sicti ti~e irom o_ _)y

_t your ~--_-~
p. 39

711

0 it D

°-_C 0

G=Si_- D ' ~=__v ~l r f I _ X ~' X n ^ ! C = G7 1: .

----------------

c 0U G ~ I , ~ I 1

~Um~~

Su3s?~3 ^=

AN ~

I 1 I ~ ~ I

(arfH o s :r~~~ ) 1 i~, r ~ I ~ 1 l l ►

- 1

. 5

yG ~T G :.S~ 01 r / + I

H- T

-:7 _

C,_y-y

r .n .

_7 J_~= ;

,.r_~-~u;

se're- =ao '

_ -. I

c=- ,I = e ~ou t

o t ,

ZGGL~10 a?~ e7_caCLOa

~

Be u :a?~~° to D° .LOCa t1e ma"' .^_u :1 Zmout o= J_'__ a- '~roll cJU ~a 0 ''-?11J ~

D P ~ _ ~ .

. . .

_

~ Tu :,, t :l_s '=Or'!:-Load L~,re1 do ~(d s e~==a 't , )

Be uaaoLe to De-fora 'vou_ (~ - _ - _ us :._= l acti'r ~ -- r o : Le,re'_ or' or-oducz:_vit :r

occ~Da_tion sc^oo' .c ; , c -,c>> h o u s~~o I ; cu~Les )

5-'-I a :oc_ `-,(LOS e c ._ -oc =o .

j- - _ -'D 7
p. 40

-

c

- - ~- - ` -

c :, ;; DD . - - = - = _ -

~_ - -

0

S C- C- -- C L7 G7 . G; - x ~ C C

cr~, 2'J= n0 a

_ _ a

5 - C ~ - ~ _ L 3 0= S L Y t-: C_. CI] r^---. ~Il C - _

LC=!.r7 T .0 ~C=__vC~_? . Y x

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7 - I ~ ~ I I ~ I s~

So~~ m ~a=~

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0

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oau-- s

d :Z e v' us. . vcs to

to A-7 )

p - C - as ODi. CQc ' Or r°_ _ ._. z l

." L c'_~

dCG t 10 Qc I ¢ :Ca - io n

~ `. 2 unable to D?- -O1L i.e 2-:10 a t '✓ OU CCll! C ._~ _

5 CO :'U_OaG L,.'r ° L QOc.' . ~ G'_ c .

~~Il¢2C__ B e to O :'-~~ v Oll : USUZ I ~0 ac ~_'I-_~_~O- D: 3 C'1 C

OCC _ .._OC . .`'=OC~'.:CCv I .`,..

~ - ` - - - - - - - -~" - ~~

,r • s : ~ u : _ =

_' '-- - - - - --=- -_ _c.
p. 41

::T-1-

y

G:

SCORING

!=WYE

_ r _ - -

U

3 -_H__C E ^ U] r- C!] C!l C r'

L0='~- L 0 x o:

c

COUC H

S ~Um~ ~

S "s = EaN_^-_= sCY. E :+ E ., :,

O R

---------- -------

S OR ^ m ER Onrs

(Or E 0^_°Sa :v .:.SS )

~

SEO r.r NESS OF >>=1_ T _

'Y A S-' LE- D -L 5 CH _"- aC E /

CO N G W T=O_y

V=l ~ ~ZZ - ~ l ~ ~ ~ :.: > > r ( ~~

WEST m T (' _-

-

~~ :._ _

~ ~~' ~ {1

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. =C _r ~ - = v= : N o

3 T H E R ; .-r TC,u E

I I -~_-

=-~_ :~ .~~ ~

C 2 ^-.. 5 2-r°- =} CIOLl'_'S ,

~ 4. T . . ° _r cause you t

A _ n ) o er to

L n C= _ a 5z O pc 10GZ' or _ a __ °' t i 0 z ..- d%' - _- f List -~_-

_~ _ -__ ZGQL tLOClZl C:°'1_C'. t 10C1

C! , . unable to perform the Manimu= 2mOlla_ of .. _ k that YOU C CU_d

Perfor m

~ Turz t h i s =Crk!oac level a0wn(c-_r-j-71 _at_ )

,~. B 2 L: .^_ at 1° to perform your usual work' act l7 _ O" 1° v °_ 1 of ' C C ll C C_ r- .

` s "- --_ _ z :OC: , =r ^00 L- _

r `_ , C' ____ KO ... S _ .__0 __ GL. z _ _ d

s_-T a! hGC_ ____-koss ____. --_ :-F

V_E_ .. Y.7W7 _ s__ __ :1

~ ~ - ~ - ' in - - - - - - - -
p. 42

D AT

COND . o

SiOHT\TG U] U] CO

' 0 NE 2 0 ='vi C 17 r.R .r.I

G: ;r U U

C2

~4 O

5='RAC~ 30=SEVERE co co n o c L cn

10='4-T LD 4 0=1 _N C?_-° . c x x c

y r~~~ C G ~ ~ r ~ o r :D

COUGH

S P U`nU M

SJ3S TS,°,NA!, SOR E N ES S

0R A'Y ^_R'~,i -I S S

SORE T°30zT

(or HOARSENESS) /

SHORTNESS OF BREATH ~ ~ ~ ~ ~ ~ ~ ~ ( ] LJ

NASAL DISCHARGE /

CONGESTION S ~ I J l { I ~ I ~ /

"WHEEZIN G

CH-EST TTGHTNESS/

-5 7',) _C T

-_G~ ~

-D

A -

C H ~

7 °,0 ,N T_^-_L : NO Y

z

S

~YR I R RITz`"10N

D `T'_1F R SSYV1 D 'nQ,qi S

( m ) ~ ~ ~ ~ T, I

~ I I

S J^~ 0[IlS ~ Q1

~eQ

s CCI1 :Cr .L

- - - - - -

several hours ,

1d they cause you to :

_ °r t o

Dec-ease oDL-tOnz l or recreational =_ .._-r :- - Lis t

Tar.= additional med_catio n

Se unable t o per=o f ::i the 7- a .c~ m um a :i oc :s o= u-orti Void cou I d

oe_ ior m

rn ;. n '_s w orUload 11 evei do w n(disr°_ -_d __~i~ue )

Be u^able t

o per=or :, rour us '_ ai on 1e r~ _ cduc

oc C a z _on, s C ^c c ? ~o -- c - ~----- _ . .u~ d cn_ )

S - y z ., :,c ._ ( se v

V - = - ~ ~
p. 43

C

CON, 13 .

(D

SCO,°, VG a ti' F r -

z cn c~ r cc f x

1=_1ONE 20=,_OJER_^ '-'_ c

5=-'-RACE 30=Sr.V L°E -

C-' X H r - ~

o: C

cn co cn o e Cl) c:

,

1 0 ='~T L D LO=~NC~° . X c

COUG H

S?UTU M ~ ; j I! i I ~ ~ I I

SiJiST E °N4L SORENES S

OR 4ir ^_R'NES S

SORE T` R oz-

( or HOARSENESS )

~cOP,T_VESJ OF 3,01aA'L J ( ) ~ ~ , ~ l I '

-iASAI. D! SCaAIRGE /

ONGrST~OV

; nELzING > > I I ~ i

:a --n ST T I G H TNESS /

D A C~ E

i ONT-^-_L : NO Y -;S I 1

. Y7_ -IRRITATIO N

THER SY'4p `i'o"?s

L L S T

ym n soms & ai _ccra_„r-

.ea several hours ,

d the :r cause you to :

e r t o A _ F )

Dec-ease oDL_oC12-l or r°C"°O z 1oC12'1 ?c .`,ivi L s t

^'a,= add itiora I ca t on

_- 3e unable to oericr _ the xum amount o : -.:o- ; t. .-~ •r cu ou'_ ^

oer ;ora

Turn t2 is uor~lo~c °~e_ do n(d ~ .°s~ar~ ---

Be unable to er`o_ . vou~ usuz_ vo :-_ ~c~_r_ ~ or c_

S--ay a-- ho .-.-- s :C-;'~ : _ _ .. .

your ~3
p. .4Wi~;-~.'4R_'a;

__ . ._ . . . . . . . _ _. - j -- .

i -• -- - -- -- -

. . . . . ...,~ .

. ° --- - . .. . .

, " . . ~

' . . . I ' : ... .

~ . . ~ .

~ t .

~ 1 1

. .

.

.

.

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. ._- _ _ . . -

- . f ~
.__0~/

, WE 0 / - - - ~ .

, _ - ^ - hy~ c -

- C C U

S 0 : __~G ~^ Z ~ c" r- . x ~ f 1 c

_

LO=----D L0=_iy~ c_ yc ` x 4 ^ ~ _~ - Cm .

:< c ` c

C~ cre _ 5 5 5 `~ ~j (5 15 I~) 5

J 2J"-'JZX-

.SUsv m :1i AL SVi._.Y_S ..

OR _"-_ 71_ _.r _ :. :. ~ J I I ~

t I ~ i

SORE TERUT

(arEOassZ :t :sC) y

SeOR"_YE5S OF c c,_A`__

1u ((~~ l~ ~ NASI ;. D ISCZs= GE /

COYGES= :OY

10 +~? I V I~ ~~ M / 0

VEEZ . ; ., G

WEST _T-GEY'~Z,~ - /

f _--

_-_ T __ .= 1 f; l 1 ~ _r`_

" :o YT-=-- Ye

-~ ~ I I f

ZT = l:=_ .n__ T _G U

~m--`~ J--'.f-^~~•!S

II ~ (~ ~ ., _ )

Zz= se-yeral hours ,

La tier cause you to :

per t o

f Dec-_ase opwioaaj LL_-

Ta'te additional medicazio n

G B e uIIZO i_

to DL'_-J ._t

:._ --- ._

t

. .

,

-

you GC_-'--

CZ : ;Q r Q

~J Tura this 4o C tL o3G !eye! QO wd Q : _ .-- _- .- [ _ : __ ' )

Be llC`o! _ i. ; D?_ _J . = your usual York' ._C . . _ T _- or L _'r°-_ of CG'1C-_ v - -

P occupation, sC :CO_ 0 .-,

= __'--- .- cu "--_ __ a s l __s l

s .. a Y a : hoot .. _ - - . ' .. s - - - -- _ • - _ ~• = . - _

C n V - = _ - V cU = s - c __ . .

V - ' - - - ' - - - -- - - . - - -. - . . .
D

- s- ^ ^

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~

1 -i?0 N E. 2 0 =-: 0D3`__ c; = c; `- - - - c2 C.

r--

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=

5

1 :.. .-. ~

? = .__ ~, D C=vC .__ X

COUG ~

S 2 U'" UM

S F. 5

0 R = , Q ~

SO R7 TE 30-_^

ca Eo~_E S z ,ri ss) I 1 1 ~ ( 1 ~~ , (

ScOF.^__I~SS OF ~ .~~r'~ ~ •

HAS,-T. D 7 SCu??C 7- /

Corrc S T! o N

N G 5 ~ {

y*~~

5

-~ ---

11 1 l~i 11 l

_~ ._.:_~, _ • - ~ ~ ~ ~ ' ~ ~~ j ; ! ~ i ~ ~ ~-; I'

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0

I

] r t~~ L~Cl~ tY Q ~ = ~~ . .Z_ lr

. ~- I \~ I

~cc se-re r a1 oo u

d ev c a use you to :

Dec-ease oD ;. i onc'_ or 7 e 27 e 1 a_on 2 ? c -- _•r~-•,

a_:e add_ '_oca'_ a,eicz Z ~o n

.,e unable ~c ae-- - aae c~ ~ u~ z m eur z o : ,,,. a- _-ou cou'- - '=c- -a '_--r

UP Qr

-

_ ~ _ ._ . t:'_5 wC^v i 02C ~-"re_ do t l G S r _ - r-d _ - .. _ J1°_

= Be una o ~=- to oe - : c 7m vou : us "i o- er~_ e= ar c c r-

{' sc"-oo! ~;c --- c'~~__~_
S'v3~~C= 0

-

D Am EE /

CD Alp

r _ - }= C <

5 :.0 R =YG CO x

- `ION~ 2 0 ='fOD`-i Cr c= c c c

E- C C

c

c CrI 1 r1=.'.T > < ~- ~-

Cr:

c y

C

C

r f G

OU G H ci

rQ"_'TJ M

3U--- ST E3^t--"- 1 S O ?. E .r E sS

OR oiv=~=-',r ET S S

jOK~ i~~On m

(or HOARSENESS) ( , I ( 1 J C5

S cORm_ ._~I r, SJ OF ER,`,_ -~~

y A sar. D I scLLsF

'

c Z /

' Q~rc~.s TTa l S 5 Gj CJ 5 ~ 5 ~ ~

~~.

-, ZiiIG

S~~~~Gp

y N

ESS/

-7C-U7

C ~ _

= CV:^L No

I= R r`rn_"' ; O N ~ l i 1 ~ 1

T ~ E'i S'L'r~^0MS ~~~~ l ~

✓ ~ I I ~ ~

_rr~~toms & disccra=c

e= se rer_1 hours,

: .L f Q~

f5 r--~' ~ ~ /~ ~ '~ ~Iv1\

d t i e r c a use you to :

v

to A -? )

' Dec :-ease ootiona ! or rec-_ a tionai a ctivit-r List

Ta'.;.e add itiona? aeiic at io n

Be unZO T e to pe :' _ o rW' the am ou nz: o i V0 '" 1i that •roli Could no- =

DerLOI" m

Tura this uorkload level aocra(di sreg a ;a f a tigue )

Be unaoie to pe r ior m vou : usu ii ' vor!t~ act iv it ;r or 1e,r° L o_ pcoc''c~ r' -"

( • ocC U p a t lon , SC :Co' C i ' ` , c _ " c 3 _ t10 us ° . ^ _ o L ~ Gud u t i e s 1~ _ S )

Stay at ho rm _

V _vc u- p^ 3 _ : . .
p. 48

rt- _ 2:,

C~ YC

=tilQ L2 (3 _- C _ c _ _ CJ C

CI;

C a _ 5 G TE C!'] c r,

==.T 7 T . D L 0= H C ~

Co Jc 13 )

.rmu m- c~

~ •Y 5 ~"~ •^^ I

fio A- °S -r- ?rL ss

~vR m N !'.SJ OF 1 0

CJ 5 1 S

Y

~c~s

D

ov

A ^c /

1 0

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JC: 5 I ~ ( ~ l ~

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r 1 I ~ / I 1~n ~ ~ 10 15

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r

^

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7)

1

C J a 5 Q'_ ~. C ;1 f O : .t ( I l 1~ ~~t/i

e'rer a ? aou~-s , ~ Ct

~ ~

b . t.1e'r cause IQU. to : l ~

to A - Fe c _ _° s ~~ O D t 1 O a z . L O L' C' e -_ C Z c'`.

-r ,

_

-----

- Z :: add 1 _ O Ra L Q1 e Q -'c at =0 C,

5 llR2,05_ tJ De :J r .-. i. .'1~ WOll:C O :

e~r'or ~

n : :: t " s s.-o rkload °z~_ z)

e unaoL_ t n?_ - o~ m _v c 'i_ ~o_ . . ac__ o, c

Oc c a .._ ., a ~ sc .,0 L c ___~ c --- C=1 c-
p. 49

~ ,~ ! = t ~~ '~ } ~E> >

D AT , ~ ► ~IC OND

~- ~ ~ ^ ! : = - ~ 1 =

CCC'-_iC x

L-MiZ_ 20= .c0D=a- C _

1 C=-? Cu ` ^ ?< U x ~ ^ as

f -

- I - -

C O crc_

:7) 'rJ

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s US:• EMA= s M _ MSS ` ! ► ~ ! ` ~ ! , l ~ ~

OR =- w =-=-=:t = S s

(o~

E

~o~,~_r E ; )

-1 1

~ I l

5 E01`"_,ZSS OF ~ ._~__~ l {! 1 f~ I ~ I ►

NASAL

CO _z G _ S __a :~ ~O 10 10 iD f I ~

c~~ E

: ,,f~ S :.

/

:=5 =°=C ==0_y

_ _

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p NT

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,

I

- I \ l \ : vo

- .~- ~==-r .~- .• ti ~ I ~~ ~ ~ ~~1.

S =,.r= ~ CME

l 1iJ='~ ` , I R 1

.. 2 = S e 'r? _' ' - hours J

If~,1 1t"Y, 1 - 'I1 ~l / ~ ~ ~\1 ' L <1 t :Z_r cause _lCCl t

o e ,_ to A-1 )

~ D_"_ _--' ZC. L 7_ , Lin--

Take 2GQ'_ t :O :I31 Ql~•='_C'i_J7 _ ~~-~ f

~ SZ l1IIaDL_ to O e r-O . - the .- -- Z?.OU_ .L of VJ _ . . t . . ._ l you COU-G : O_-

D o rCO r m

P Tura t :'_S 40r t

Be l27?_O L _ CO C?-

1

03G 1

;0 :~.

1 Y

your

I

_ i jT

usual VO :' :C1 ZC t

_Y_` O" 1_'T_? O

: D["OG'1C = j 'r

~ t O C C - 7 = t_ C Z C - - _ - -- - 10LL5

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:,J10 -C ~ 0

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1 = jO_ _iE 20 =--~~- R '---

_

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_

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10-VELD -

G.

.,-

COUGH c~2 ~ s s 5 5 ~

SPJmU V

Su3S1EaNAT S03E27~S S

OR AWARENESS 1 I ~~l ► ~

SOY^ TMp^ T

(or ECIA°SEi1ESS)

1 ' (

"JR^_"_{ESU O= -.l3_^___ J I ~ ~ { 1 ~ ~ ~

I

1

Y,_ E __ ; . Cor;c ZS T

DMO

=o ti

u__ aGE/ ~b 5 5

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RES - R _C T _o_y

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_: . .v ~ _ ~ ,_Y -_~~~ 1 1 I,~ ~ ~ I ~ . '

_

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( L =JT

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)

MS I I I I ~

symycoms &

,lei 5 2 v ° :" ? ! ho l1 r ~ ~

1111111i1 I` ll J

L .7zr CauS ; YCO to :

t o d _ ~ I

~~?C'-~52 O^vLL^i.Zl or I'°`-_'.? n :.OC?? L activtty List

Take -ddition,L medicatio n

C' ,_e unable to De_ _3_m the zamiaum 22Ot:=, O : -,"y t ,.`- '/pu C . '1_G GC_~ l .,r

c°__ :OL' a

D`n'1 :'n this =0rYlOviG love : do '_ i(Q'_5 _ - r G :_t_,C.? )

b e liC`bLe to Perform your l!° ;

. .1_ c.-c :

. . a C t _,-` G .- level of rod '~C z _' -

(' 0 C 2 _ . . ion ~ critical ._ C u5- ._ c __ G'1 :__ d

E : ax 11 to -~ . - - - - - „ ~ - _ - - - 1- ' - _ ` _' _ _ . _

~ ' - - - ~ _" c _ _

. _ T - - -- : .

7 i-f - ~ - ' - ~ - - - - - - - - ~ - . 1 0
p. 51

GROU? lY ~

SJn jECT

COND

DATE

E- c c~ z z

.

SCOREVG a CC M x

1= :vONE 2J='10D~R^ "_ v m E c ~ r c~> ~ ^' ~ ~ _

C 0 =S C_ ,J Cr u . rr-., (/7 p L-;

co cc 10=?.17 LD L0=7-VC,~-° .

x X

COUGH

S?UTUM I ' 1 1 I l

SU3STEqNAL SORENESS 1

AWARENESS ~ OR (

Q

SORE THROAT

( . .ca_ Rs -

::Ess

SHORTNESS OF BREAT H

,r A s=-= ~ S"C us FGE,'

CO[JGRS 7 =0i1 1-5 ~

WHEEZIN G

CHEST TIGHTNESS!/

~

RESTRICTIO N

FA `:'IGJE

FRONTAL : NO ~y =S~

"

OTHER SYuD`"oMC

is ~r I~~ J l ~~ ~

sr-z-~toas & dI =_ccrs :c_-

a stz d several hour,-

-ou _ d aer cause vou t o

:. . De^r__se oc -,_c . . .__ or recreationa

. ':a_:e adc_t=ona '_ ,. ._-~_ca tio n l 3

C . Be una .,__ ~„ cer_j ._ the raa :czu :n a .. .~1 . . ., e_ ~o ,,cu could nor Ma - :.'

czr_ :~ __.

..

. -----

--- ~ ~_--- --• _- ~~ :-,_--- - - = - --- _

--

(~ ,~~ -~-- -----°-- - . -----=-- - -= -- -- ~_ :_-~
p

. 5~k _"-

42-

7l

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1= :;Oid}

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to

Tz' _~zca a_ __ on~

D~c' oo ac_ ar r° -_ o 71 zc! ; ~_= a

'= . ._

7

P u r ._ ., _ _ _, _.. ? _ _ •~ _ '~ : 1 _ 11 . ' -., _ . _ ~- ~ _ _ . _ _ " _ ' ~ _ . _ _ _ _

. _ _ _ ~ - _ , _

.

V O C - - _ - _ _ ~ ' , - - - - " - " - - - - ` - - - -- - ' - - - - - _ _ _
p. 53

c C :.~ ~

y S = - _

.^ ^ C __ __ ~_ = :_ ,_ •_

5 C 0 a - C

L= ::0 i4~ 2(3= C2

- y- - -

G: ,n ~ rr, c _

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c 3 U e 77

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SOR T

(or~ Eo~_Rs .r~s~

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li e 110 1 0 lo

D C u~_ -2. C0 c ~~ ~rc_-51,- 1- I to

C sT ,~~Y'r-.~ :,/

1 -t7

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1Q t :l e_r C l u ~- e you to'.

•- `.J S _'.-~ -

A pec~_asz ooz:ioaa? o r

g 2 acci ~iooa " a', ed ic 2- tion

C ~ 2 u : a o to D Z ;' = o ." ll i, i e

D T1 : .. .-crr1 oad 1~ ,r~i ao= .(d~sr L :z a7 i _

Be uaac__ ne ;or~ vou u or ._" ;_= c ;

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p

.

5

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-7 Z

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_c cuse vou to

~ 17°_C'°? 5 2 O D C lOCZL O r On ~~~ a Z .- - I_ - 7

~ zi 2CG 0C;2 S° a C° _O ❑

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p.5

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lor ROA °S ) rNESS « ✓

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3 cOR`",lESS OF

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'_ONG c,Smrp v

rIG 1 I I I I I ( ' 1 i ~

~~ST T=GH~^"I-SS /

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_

0

. i NO

\ 1 i 1 \

_

7 -) ~;, ~ a 4 I

_r~~toas & di =co~

z sev er a nours

d t-e,r cause you to : C7

t o ,.- Ff )

Dec-2ase ootionzi or rec-_ntions ~.ctivitr Gist

m .'_ ~- ~ ~ acd : ona? meaicat io n

Be unable to pe :- :O :' ... the ^a :cLtm `-ou ;?t o : 1? VOIl COu a n^r --r

C e f o T- ~

T's_u t cor?tloac 1 .ve~ ao_ c,== . e r~ r~ .._~'1-

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v :

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a act

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. - ~ ' ~ -- ` - - ~ - - - - :' ~ - - . ' : .. . ^ ' - -- •

i ' - ` - - - , - - - -
p.56

C a SC

0 V E. 2 0 CD_ a =

-C ^C~ 67

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to A- ;-Z, )

) e c _ e ~ = _ o o L i o n z ? or r ° _ r _ _ Z: o n a _ z

e 2.c.ai ona? n e c a ~ oc,

unable to O' - - 7 i. :i_ 'o u

un0i. ZD •fcu- u~ -

c,-_
p. 57Z- , JId I R oU P

1'2

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SUBJECT NO .

DATE_

H '- C

COND . ~ c ~, ~ Y ~ z ~ z

SCCRING ca M ~ H Q <

H H X

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= C - ~ V G

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ri E, E-•

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COUGH

26"

SPUTUM I / ,I / I 5

OR AWARENESS / r I / / I l

SORE TEROAT

(or RCA°SE:ESS ) 1 J /

SHORTNESS OF BREATH

,I r

?VASr_r. DISCHARGE /

CONGESTIO

N WHEEZING

I

CHEST TIGHTNESS/

RESTRICTION

FATIGUE P5

HEADACH E

FRONTAL : NO Y ES / I

EYE IRRITATIO N

OTHER SYMPTOMS

(LIST)

~ s Ym n toms & dis c e_ort

'-s Z ed several hours,

D uld they cause y ou to :

H 2--=' LO d.-EI )

A . Decrease opticnal or recreat i onal activitv Lis t

3 . Take additional medicatio n

C . Be una b le to perform the maximum amount of work that you could normally

perfor m

D . '"sr ._ this wo--_?oac leve i dc ,.n(disre c- ar d fat -3u e )

Be 1^a .,__ to your usual :nr k ~ aC _-!= or level of OQl 7_ i

Oc .^_llDa z _oC, ~3c .^_oo lwOr . , critical } 1O u S

10--e time : o ^, tC _ V
ss, /

y~y C

U D .

~~ ~ ~ O ~- ~ F•- rr-~-- ~ i=~ ~".' ` ~. F_

~

0 -

~

.`'IN Co Co F- X ¢

F-e F-~ F-~ f--'• 1--+ G: ,` = U C.:

3tON:1-: 20='4ODER_^

o ~ ~

C Q c~

~

~ C

30=Sc:VE3L m M_

_.~ . r -7 ~ D 4 0= YC r

., ~ c= _

: z

AUGa 1 ~ ~ ~ l l i~

T-J

,~,tt3STERNA

L TUM

SORENESS -

4iYARENES S

703E TEROA T

fi0P_4.Sc Nr,SS )

~QRTNESS 0F'BRL^-_Tfi

/ / .

AAL DISCHARGE/ /

ICcST10 Y

~gEZiNG

EST_°i1 C TIGHTNESS/

T

!!1' c:l E

1:v,/

C H E

KT^-_L : NO Y, E, S

IRRITATION

" R S YMP`z'O XS

LIST) TI I

.otoms * & discc ra *' ;r +-

se•rer=_1 hours

he,r cause you to :

t to .~-d )

)ecrease optional or recreational activity

"ak.e adaitionai medicatio n

e unable to perform the maximum ZmOLLnt of work t7 a- you could normailY

•riorm

-n t~is vorkload level dova(d :sregard Lstigie )

unable to oe-- t or, _vour usual ue ;- k 1 zct ;.•r?t; or level of p '--OauCt1`r_ty

'C C 1D at 1oQ, SCClOo_'.Or_:~ c :- : 1C3~ QO115~^O ~~ G1~t~5 )

at hom e

your - r~
p. 59

GROUP (~2 6-2 7

SUBJECT NO .

DATE J ~O- ~ ~ c ^ ^

F-i L thV-6- COND

. o w e r=

a z z

. + SCORING ax

H ~

co H ~ <

1=NONE 20=MODERATE ca o

10

5=TRACE 30=SEVERE 9L

x H x w x x w U'

. c-a cHcHn w o coHw `-

=MILD 4O=iNCaP .

a w w cr eP4 vc c; oc a n, cCOUGH J /

J /

~

SPUTUM

SUBSTE R NAL SORENES S

OR AWARENESS rr ` L,

SORE THROAT

(Or HO?_RSERTESS ) (f ~ ~ L ~~ !!~ ~• ~'C

G , ,!~,/~ O ✓

SHORTNESS OF BREATH

NASAL DISCHARGE/

CONGEST=ON

WHEEZIN G

CHEST TIGHTNESS /

RESTRICTION

FATIGUE ~ // ✓ /,~ /

HEADACH E

FRONTAL : NO YES n /

I

EYE IRRITATION

OTHER SY M PTOM S

(LIST) / + J

=r s ymatcros & discom :or.t / - --- -

lasted several hour s IT

aould the y cause you to :

( Refer to A -H

. Decrease) A opzional or recreational activity List I

B . Take additional medicatio n

C . Be unable to oeriorm the max i mum amount o f work that you could normally

perfor m

D . Turn this workload le•rel doT.:n(disregzr3 iaz_c-•ie )

~ . Be unable to L?r_ ~ :- . . . our usual wo`_'-i 3 = J' l c' -- of L 7C Ct_ J- _~

(= oc s~ati~r., 3C - .cc_,:c . K , = - z _ca house-o
D A-T 2- ~ C-1

CO er D .

SCORING

?=?70 N*.' 20 =MOD = IIRI " TZ %'

5

=•- a I

LrJ=ar._D C~C~- - -~ L ~

_C : j 0 =

: 7- ~ x ^- x ^' x ^- ~ ^ c V

S c v a ~ ^G• c7 ~n C G cr; C C

COUGH 4~b

SPUTUM

SVB S1EaN1L SORE-NES S

O R -ai;=3E:t~SS

SORE mc-4ogg,

(or

S

OA$S4YL.SS

JcOR`" NF.SS 0_ Da_,A `?~

CONGLST T ON

`n --77- ..uitiG

CuvSj_~~r0

Y*{ .

: J~ i

✓ /

v I !

O l{r - .S

_

i_. I i: ~ m e_ r! Q lT ~1 (

IL S?'~ ~

S'ti~L047S' Sc Q15C`^ :1-0 :. ~

te~ se•re_a1 hours ,

Ld they cause you to

OOL10C12 l or recreational : Dec-ease 2C?i r i

~ Take additioaz_ meiicatio n

1 B e unable `~. .7 De=- :Jra ti2 M z :C' = ur1 amount o G-01ti

t .-a- VOu c^tl l G ,^-^•-- al ? :r

'De r f ar m

Turn t s Gor!~1oad Leve1 doc a(d sre~a :d f?~1~12 )

Be unable to oe -- _o r

: vou= usuaL -oractiv? t-r or 1e,re' c prcauc t :r

(' occuoaton, sc`:oo'_-.:or:t ccho Us 42!'-0 L,4 d u

= S,-•r a_ h:, .. ._ __c__ .'_

=
~..-L~ ~~

I I

SuEJ=C =

D

.~

- •

/ ' ' • .Ej

~ c

.._ ` `,

: c z z

CORD .

• _' c e= ^, ^, _ = ~ ,.: ._

SCORING ~= z m c. F c i- X ~ <

1= N 0 9 ?.' 20 =MOD _1.1 "_"E ^ a' = C C C_ C C

cz

C

(!1 G^ L cr

:

10='r_1D L0=7 _ZC" ^

:

. ~' >` ` X ^' X r X ^ c ^ C

~

COUCc ~D 1 l

SPUTUM D I

Ici

SU 3 S 1 .`~. .~iTAL SORENES S

OR a:,AR r:z ES S

Svr.? mE3 O_"-_"_'

~OZ~1O~DS f'.~.~iILSS ~ f

SEQR`_7Y.SS O F

~~ ~~?~ /yo r I J ~

F 15tL D7SC :s~G7-/

CONC -IST_GY

`,v HE ~ .. : 7 i`TG 11016 5 5 I

E * S =': _o_y 2 (~ 5 1101 1 5 I

_ .:___~~ o • . ~ I

TI

rr`

O :r"L . :1(

.-,:`~~O~I D -•~~ I-~= f

5 : ut JG1s d1 :cc :1_Cr.'

z2^- severs_ h0ll?'S

Y

1d t :e ;r c=use you t o

t o

~ Dec--ease ooLioaal or recreational activit•f L_s i

~ Tate zddit_onz? me'dicat_o n

~ Be unable to perform the ^z :_^t1;Il z=ou''1t o G-J t1' ~ you could Cor::1 .2--1 l

.r

Der*orm

i'llrm this vor~Io3d 1-e7e_ Qo-- :(dlsr°sc:S i3`1 .^'1~ )

Be uaaoi, to per?or ., vour usuzi -or'.t4 act :~rit•r or 1°v°' of pcod~c

occioazion, sc~ooL.o-~, cr_cica'_ hcuse^o Ld du :i~s )

- ('c _ -o.

=

~-=- - - - ---- - .- - --_ ;
~' ~--1 ~

c

'_ gG

DI , .~~ DV~ ~ ~ ^ c

_ _ ~.

C'ut4J

1=;orTE 20_C`0_ a `_-_

- e -- C

~-=-C=- Z 30 5 E ~~ :._

L^='___ C

C 0UC-= 1 ~

S?U`"uy- ~ ~o l

s~i::si~'~is0 ~

o R A.4 a3 E:r Zs s

o

SORE ^* -tOR j

~O~ ~'iO~~SGVLSJ ) /

m e /0 1 lD lo

[ o 1/0

~

. ~ I 1 I I ( ✓

,5 A D S 0 4s ~ C- 7~ corrc :.s T _ay

v-=-,7- _ 3c

lhD Ii

:C`?~C y

77

0 NO

Jmr n ~ / ~ ~

2_ se7?,- a 1 aCU?'s ~

'd t~e r c_use ycu t o

-=r to S-^~ \

Decrease oDL1oQ al or activit y_ L'_5 .`.

~ `i2a° zCQ i i.ioQ2.- 712-1 i c? t =o n

Be unZO i e t J De 7 :O r i. .Z2 UII 2 .' .^.CUD C CC ~ - rCu C C tl_C ,- --~ -

Der*orTsrn t :~ s uer_cload

= Be un ab _e to Dzr _or= rcu= usszl -or j act•rr - o-- 1~,r e_

2 ' - ' z Z ; a sc- cc -',;C r . , c r

=-

_ '1 - -
p

. 63

D

J T

-

n

t.v YD

~ .=

5 c 3 °_xC X

1= -1O 97- 2 0 =:CB=-3, _ '-~ c: C; c: ^ c c

cn !:.z a: c cz -

10=`.:__C ~-C=t :YC '

cocrc=

sP t;TUM ~.

s U3 s TEaNt-7- so R = :r-- s s

O R

$v+.7'

t~ L ^

.' . `~'`<Q A n

~

(or EOP_•_°tSc. :rc.SS ) ~U' )

S =o Rm~fEss OF a 'a -cr r_= ~,L~ ~ I 1 I l I I 1

N 3s ALL a T sc~ a

-

F

"

GE /

co~rc~s~_o~

ii_:1LH H

v~

E

v

7S3

ON

4 3

~~.AJ ~ 1/0 ~ o :~_= . o

_ T

= T- =__'"_^ ; o f

~"•_'T== : S•_~.s_rt0~.{~ I

' 2^_ Several laour s

L Q t:eY' C? us e Yc ll t o

-'

.

A - C

~ De C'°9se oDL1oGZ} or r°^=°__ .`.LoCS l 2ci.1'r? ,7

`L' a i° 2QQ'_i.i.orZ_ Ql z~ •11cP. t 1aCi

1 Be 11R20 i _° J De-fora 1e z '" m 1rS 2^ot1C z O ; LJ' .; ` . '! f Oll C LL_G

Der-For m

Tura this uor4load l_,re -', do n(d_sre~~ : ; _~•e )

Be un~o -" - t o oz-'or,. vou : usuz'_ or 1_ .r°' c : orcc' C__`r--f

( occ ~z~ioa, sc' co'_ "----, c - _ __ ~cLLS_ ._ ?c __ - )

a t

j-' - - -
p. 64

N 0 6~/

D

e:t :

~JLA-7 J~

S i. C a i aFC P3 C.- ?G G -- -

C;

1= :i0~TE 20=',:oO~~R T .~

CC = c c c - c

5

_--1H "-C E:T jOSc; v - E ~tl C G-': ~

10='-,r ;LD LO=I _CC1° . X ~ X >< ^ I X r= ~ ^ ~ ~ -

COUG H

S P UM 1 / ~ ~ I I l 6vSUBSTZaNA-L SORENES S

O

or a R SOR E

O AusG N

iSJ) I ~ 1(

ScOR'" NRSS OF DR=: A '_' =

✓

MA-Sr'_i.

CONG~ST Off

V =-L 7- Zr -7 N G

/'O

,

' •~ ~ ~ ~ _

i

. _ ._

7 0

. CmU S

V

s :ii^_Qms ~ a1s`^IS'C:.~ ~ ~ 4 ted se•re--al 'nours , l f. ~

1d tze ;r cause you to

t o s. - V )

~ Dec :-ease ootioaa? or r°^_-°ational act=r :t_r Gi st

`ia :l° additional Qled'_cStion - ~ } !

to per :o :M the ma :-:!=Um amount o : Gor'.t t :tat _rou coula r_or.

._--

~ 8e Unabl e

oerio r Perfor m

/j Tura t :i s workload level doc ,(d ; sregard fa-431e )

Be unable to Per_o-y our usual acti,rit_i or le,re' of DroQ`1C`''v'-t"r

o c z u n a t ' _ o n , s c :oo'_ o,-'r c-_ i^_=- =ous~^o 1~ dn °s )

F S
p. 65

1. 9

' ~ . ~l vd S~1
r , ~~i V ` -~ ~. ~

- /

Vi f ~~`-~ '~ ~~'•'C ~ ~jyt-~ Ji~i 1~ f. ~P r :.1 ~

It

GWUP It

l

St1BJECT Pm . ~ ~

~ 1 1 ^~7 .

f ~9Ur~

-7

DA= 12 6~

it -~-f C?ii C7 Exertion

Z

COND . ,~. ,-f cv c~ 2 , Scale

SCOR= r=3 cn cn

- `" `Y' P.

0---No thin I.- -~UNE 20-.MDERATE P U H F,

U3 M

~ ,

~ v} o f f c~ +•rn cn at all

~

43 o O CJ 5=TRACE 30=S F,V~'•cE ' ' cr~

10=`~,D 40=!NCAP .

I f f ( 0. 5 Very, Very

Little

,I ) `

COUIM 1= Very light

SFCPAlr1

2= Light

S'uBSTE,P?'IAL SORENESS

OR AWAI;ENESS 3=Moderate

SORE THROAT 4 to '•5 =

(or HDA`RS ERNESS) Sorrt-_vhat

Heavy

S'ti0RTNESS OF BRE AMi

S f I~ ~ I ' l I, r 16= Heavy

NA-SAL DISMARs...~/

CONGESTION 7 to 9 =

I I Very Heavy

W=ING w~ Q' 1 { ( ~ I I (~ r ~ j I/ 10= Very, Ve'---:

:

=T TIG£~TNESS/ Heavy

RESTRICTION

I tf

FATIGUE

H~~DACHE

FRDr~rAL : Nv YES

EYE IRRITATION

OZHER S

(LIST)

'2=NS • _

t f ,

BORG E=ON

SCALE (0-10) tt

If syumtcros & discomfort

lasted several ho ttt

would they cause

ur

you to

s, --

ttt

f i t

A. Decrease optional or recreational activity Lis t

B . Take additional medication

C . Be unable to preform the ma.Yinnmi amimt of work that you could normally perform

D . Turn this workload level wn~isre~ard fati~e)

F . Be unable to perform your usual work activity or level of productivity

('` occupation, schoolwork, critical household duties)

F . Stay at hcme sick ( lose sick time from. uror'_c)

G . Visit your physician

e:`'r`c_^.cy rccI'.1
a=,~.4 p.617

Gaour, ~ I t

t

S=GT I.D .

Borg

DATE Exertion

COND . o r-+ C14 c*, Scale

SCORTNG

H r-4 H CV H M Gxzll ( t ~ ;TT

1=~NE 20 ~DERATE 0,-Nothing "

M cn cHn o; U3 C/3 E' at all

5=TRACE 30=Sr V~'~E -4 C (COD

w cr~

10,-= 40=INCAP .

0 . 5 Very, Ver7

Little

COUGi

11= Very light

SF=

2= Lig~ht

OR AWAF~~SS 3= I"

SUBS=AL SORENESS

bderate

SORE THROAT 4 to- * 5 =

(or HOABSS)

Heavy

SHORMSS OF BREATH.

16= Heavy

NASAL DT.SC iABGE/

CC?NGrrSTION 7 to 9 =

VerHeavy

W=ING

10= Ver-. r, Ve'-;

=T TZQHIiqESS/ Heavy

RESTRICTION

F=C--uE

IT-9DACHE

FRONTAL :NO YES

EYE IRRITATION

0=S=NS

(LIST) IlL! ' l

BORG E)=ON

SCALE (0-10)

If symptom & discomfort

lasted several hours ,

would they cause you to

~ l l l_~ I

- ~ - i-+~ -

A. Decrease optional or recreational activity List

B . Take additional medicatio n

C . Be unable to preform the ma .~dIIn= amount of work that you could nor mally perform

D . T= this workload level dow-n isreUard fatigue)

E . Be unable to perform your usual work activity or level of productivity

(* occimation, schoolwork, critical household duties)

F . Stay at home sick (lose sick time frcm wark)

G. Visit your physician

N . Visit an ETeroe_^_c',7 rcCT?l
. ~ ' • /~L~ _Y~` / +/ ~ 11"_ -l.i Jl"~.' : `. ... .~._ p. `

~y$ • I

I

GROUP

DATE Borg

SUBJECT M Z-3,39

E:ie rtion

COND . oi l

r--4 cN C•, Scale

SCORING ° r~ t5 w w w M

xl~i _¢ ip~

cn; 2 co r--4

`V `n

1='-.'UrIE 20=-%,!ODERAIE 0=~ H C-- H z, H t~ot1Lng H cn cn cn o w cn cn 1--4 at all 5=TRACE 30=SEVERE ►-~ w ~ ~ ~ c_ Z c o r~

a v1

10=`~'-= ~ 40=INCAp . 0 .5 9ery,Ven7

Littize

MUM

SPUTCIM 2= LiQn1= Very light

t

FUBS TEKITAT St7R=-S

OR ~IP_IE, S 3= ?~cerate

i c

(O ~ ~t,..

.S) L to 15_

I I Sc~~ v~.a=

- ~roR~~-~.:S 0F BRZ~~ / ; ~ ; ~=-,:

CO.-E-MaN ; to -

~ VEO i : °...: 'Tv tivr ~

. .7LC- I

I ~I ~~ I ~, ! l I 1 i~i I I 1 ~

l++

.r~-r~+ _0= VE_"7

7

Ver:

ii~1 11l::! i ~v/ - ~ I I I ~ L°'_

vy

=S'~~ON .~

► ~I, , !

-- - ~~~

- = ~- ' -~~ • ~ ~ , .

G=

3C=~ E: ==-O

N (0-10) ld

If syemtoms & discomfort

I ~II I lasted several hours ,

would they cause you to

A. Decrease optional or recreational activitv List

B . Take additional medication

C . Be unable to preform the maxunum amount of work that you could normally perform

D . 11= this workload level don aisre~ard fatigue )

E . Be unable to perform your usual w-ork activity or level of productivity

(* occupation, schoolwork, critical household duties)

F . Stay at home sick (lose sick time from work-)

G . Visit your physicisr:

H . Visit an e*rergency rccm
. !/ `.L` ~fy, ✓

4 A~ ~~f~~~~ p

. 69

SCORE Sr=

MUP- ~

s'JB.TECr 'U .-Lo A3 -'16

DATE Borc,

E.Yeotion

COND .

C Sc:1e `1

SCORING

z cn c„ cn

W c:a

1

~~~+ ~,y~y~ ' d ~+ A

L~1

~ , ~ ~ ►- ~-- F; C14 ~-+ c+~ 1:1z" i 4

=1`NriL 2o'1JDL. TE U. U U

' ' H H c U.N Fi w at all E-4

5=TRACE. 30=SFV1~' a

-1

c-""'-' o r10=.= 40=iNCAp .

Cr

0 .5=Jer7

, ~y V rLitt,e COUGH

SgLMM 71= Very li~u

I/ I I ( I ,~, ~

S'o3S ~*~1•?az SORE -NESS 2= Li2~,jt

OR S

, 3= ` TI I --nde==t • , -=

SORE - A-T

(or ~ t0 'S = ~ ~~• ~ l ~ l I l~,~ ~ t, ~GL~L~X~:Gt

SHORTNESS OF BRi.~''

~ ~~1+ F~_v;

Si`~1 ! I~- i I I ~' ~

I

NASAJT J D,

16=

CJ~1=- S ON

to

Ve=; =°.;v-•:

_ T

~

S

~ / ,_0- Ve,-, , `!e_-- (ZEST

P\F,c'gZ~.=

N

r

=

cE-~_ _ I +

:73C-N' _A_. IS

o=--, S'±-

CL-, s'~

3CRG E:=L! C:i

SCALE (0-10) ^

If symDtoms & discomror t

lasted several hours, " -

wz~uld they cause you to

A . Decrease optional or recreational activitv List

B- Take additional medication

C . Be unable to preform the maxiirnsn amount of work that you could normally perform D . Ttirn this workload level aawaisreQard fatigue)

E . Be unable to perform your usual work activity or level of productivity

(* occupation, schoolwork , critical household duties)

F . Stay at home sick (lese sick tit*xe- from work)

G . Visit your physician

H . Visit an emergency room
GROUP

p.0

I

SUBJECT t~ . . OL7

DA= 5 Z Ct Borg

fill E.Yertion

COND . Hit I

r-4 N Cl) 7 Scale

SCORING w

cn n c c~- ~n

1='--IUNE 20='-,,D DERATE H'-' ~ N ~ M c-xt

~ E-~ ~ ~ othing t t~ E'' 0=v:

~ ~ Ell ci, ~ cn ~

-

~ at all 5=TRACE 30=5r V~-cF, w W, ° ° cn

10=-1!T-1,D 40=?NCAP . 0.5=Very,Very

Little

COUM j

1 I1- Very, liht SPUTUM

SCJBS=1•?-"-T SOR -

.F`it~.SS

_12= Lia~nt

/

OR ARA--RE-NESS 3= `~derate

SORL T EU?T

(or I~. -c5) 4 to aR.,^ f 1 / J t , ' ~ ~ ~ s . . C- .Nbzt

t Hea ,-v

SrORIMJ OF BRF•=T' / ~ I i I I t' t , ,

~ 1 6=

a ~

, , N~S .tGN t t

7to°=

:+ .' i V ~_

t

~' I I 10= Ve=y, Ver- C<_ RESTF, I

.JT T!C=!ir

cr=oN

:S/ I ' I' ~e='vV

C 7:z7) ~ t+ t I i

BORG E=:10N

C C"=- (O-,0) I(/r~ ~ lO ~~~ D~S~~ D D I V /'/ ~ O ~

~ '•~~ t t I I IU I

I

L symptoms & discoIILLOrt

lasted several hours,

wvuld they cause you to

--

(.r

A . Decrease optional or recreational activity List

B . Take additional medication

C . Be unable to preform the ma.xzi.nayn -=imt of work that you could normally perform D . Mtrn this workload level n aisre~ard fatigue )

S . Be unable to perform your usual work activity or level of productivity

(* occ~.mation, schoolwork, critical household duties )

r. Stay at h=e sick (lose sick time from w-or'_•c)

ls . V1slt Your physician '

i H . V1S1~ G^ ~ :[?r ;A__c'7 rcc^ ._ ~ 1 ~

;, ~ ~ / ~✓
SY`'Ii PTOM SCORE SHEET p. 7r

I

GROUP v

SUBJECT M . ~~~--

DATE Borg

Exertion

COND .

I r+ C14 ~ ~ Scale

SCORING

ClWcwn ~ i ) ~

1=NONE 20=~DERATE p; ~ ~ r' Cl) thing

H c~n at all 5=TRACE 30=SEVERE

°a rC' 'r

10=i= 40=INCAP . 0 . 5=Very , Very

Little

COUGH

Very 1 SPUTCIM light

2= Light SUBSTERITAL SoRII~SS

OR A

~ l

WARENESS 3= Mnderate

(or`'H~S) 4 to 5= Somewhat

SHORTNESS OF BREATH Heavy'

NASAL DIS 6

_

~

/ .CHARGE

CONGESTION 7

7 to 9 =

Very Heavy 1+1H=ING

. CHEST TIGHTNESS/ 10= Veryry,, VeY_ -,

RESTRICTION Heavy

FATIGUE

HEADACHE l r " /

FRONTAL :NO YES

EYE IRRITATION

OTHER SYMP'IONS

BORG p ( ( ~ ~

(LIST)

EXERTION

SCALE (0-10) 10

If synmtoms & discomfor t

lasted several hours,

would they cause you to

,

A . Decrease optional or recreational activity List

B . Take additional medication

C . Be unable to preform the maX; m,rr, amount of work that you could normally perform

D . T1= this workload level awnZ3isre~ard fatigue)

E . Be unable to perform your usual work activity or level of productivity

( occupation, schoolwork, critical house-hold duties)

F . Stay at home sick (lose sick time from work)

G . Visit your physician

H . Visit an e?r:er-ency room , /
S`s°fFTCL1 Si.v:L. S'r

.i p' 7I 2

GPIDL1~ _

Si1B

DATE Exe

.7Et,'T Iu

. Borb

rtion

CONID . C14 rn Scale

SCORING w ct

H r+ H C14 ►~~ cn 0--Nothing 1=~NE H H z H z, , H H at all

5=TRACE

30=SEVERE

P-4

° °a

10=M-= 40=~ICAP .

0 . 5-Ie_~y, Ve7-y

Little

COUM 11LLILL±iLLL1=verylight

SPUTLM

10-d~ 2- Li,-4-it

SuBS=MaL SOP=S

OR. A1vA_SS 3= Nbderate

SORE M-MAS 4 to;5 =

(o2' ~~OARSE117-15S) SOt'i~'aZ7at

S'rK R's~' E.SS OF BRFA-M I

I 1 5= -Heavy

CONGESTION 7 to 9

Very He--,,y

[vh~: ZIr1G 10= Ve

ry, Ve_r~-

-=T TICH=S/

PZS=C'7-ON _ f ~ ~~ if,

~~~

CTUE

_~ -12ACHE

FRDtv~'1. : 'NO YES

~Za =,-ON

0Y--= ST^p'1UNS

(TLIS=)

BORG ~.~'T'I0N

ScLAIE (0-10 ) D 6117 ~ ~. lzo/ I~, ,

If symptoms & discomfort

lasted several hours,

Nz~uld they cause you to

A. Decrease optional or recreational activity List

3 . Take additional medicatio n

C . Be unable to preform the ma-.cim+~ amount of work that you could normally perfor:n

~ . Turn this workload level a ~wnisregard fatigue)

Be unable to perform your usual work activity or level of productivity

(~ occunation, schoolwork, critical household duties )

Stay at home sick (lose sick time from work)

Visit your physician

>

i . Vis it an er~ ~e:~cy rocm

'

rL
5~~!~ii Jl~l i CL r 1 7 p./7

GROUP

~ Borg

~°tion

COI~ID

SCORING

. Scale

H N H c*]

1=VONE 20-yJJDF~TE

E-4

c: It ~ 3 O=vo thing

F-4

5=TRACE 30=SEVE`'-,F w at

all

x w a a. a cr~

10==Z 40=1NCAP . 0 . S=Ve-y, Very

Little

MUM

SFUTZPT 1= Ve~y light

2= LiQnt SJBS"~.I?AL SORE".~

OR AI~iA S

3= I~derate

SORE :OAS

(or HDA.RSamSS) ,/ / 4 to 5 =

SCt~*vi]ct

S'r_ORTi~iESS OF BREAMi Fe='

i

IMSa.L DISaW 1 6= 'Heavy GE/

CONGESTION „f, I 1 ( I I i/ I/~' l 7 to

Ve_y He---v-,7

CHESTTI_SS 10= Ver-~', Vey

RESTRICTION /

Flea-,,y

F.a?'ICl 1-E

FRON'T?l, :NO YES

.,, -=ON

(LIST)

BORG EXE7-17'I0N

SCALE ( 0-10 )

If symp toms & discomfor t

lasted sever-al hours ,

wca.use you to ~ ri ll 4

- ' -

~

A . Decrease optional or recreational activity List

B . Take additional medication

C . Be unable to preform the mauxina m. amount of work that you could normally perform D . Turn this workload level dawn aiSregard fatigue)

E. Be unable to perform your usual work activity or level of productivity

(^ occupation, schoolwor'.~c, critical household duties )

F . Stay at home sick (lose sick time from w-ork

G . Visit your physician ~

H . Vis i -L an emergency rocm

~_.
\ IV

.........

\trp ~-t p

. T4

~

~, (7

j ~JECT NO .

DATE

{ H H

C OND . I (

O 3 H H E ~ w

Z H H / F ~ Z

,,~ w

► .3

a x z w w H ,, , E . . SCORING m ''a~

0'] H p~ H W

1=NONE 20=MODERATE F ~ H ~ H H H ~• c~

5#T~ACE 30=SEVERE w a ~ W ME-4 W E-1 a H

10=MILD h0=I14CAP . 3 W a w w x w a o w a x

cc w v~ o w

w co

w cc ~ a a

COUGH' I- 15T (7(

. ~

SPUTUM

.~S • ~ ~

SUBSTERNAL SORENES S

OR AWARENESS

SORE THROAT

t ( r ~ (

(or HOARSENESS)

SHORTNESS- OF BREATH

NASAL DISCHARGE/

CONGESTION

WHEEZING

CHEST TIGHTNESS/

4A/ RESTRICTION

i :

FATIGUE

~

HEADACH E

FRONTAL : NO . YES

EYE IRRITATION

OTHER SYMPTOMS

(LIST) \ \ 1

Lf symptoms & dzscvmPq. r:t

lasted several hours A .,

would they

.

cause- you to :

(Refer to A-f

A . Decrease optional or recreational activity List

B . Take additional medicatio n

C . Be ' unable to perform the maximum amount of work that you could normallyperform

D . Turn this workload level down(disregard fatigue )

E . Bunable to perform your usual vork* activity or level of productivity

(*

occupation, schoolwork, critical househo ld duties )

F . Stay at home sick(.lose sick time from work)y

G . Visit your physicia n

H . Visit an emergency room
p.,75

• GROUP

SUBJECT N0 Y,'

,~

DATE

u

o

E-4 H C7 ~ Z z

~ H H z z w w

C OND . a H H H H w ,a a

0

H w o w w w H H a a ~ a a

H

SCORING a a z m rr~ H m H X a x x

Or ~ H . H H H H H W ,,,'~ • ~ U

1=NONE 20=MODERATE E

SC o x a E-4 E• E+ z E, E-1 c

5=T,RACE 30=SEVERE w 0. c7 w M w Cl) w cn 0 w v~ Cl)

10=MILD 40=INCAP . W x '-' x w x w X . w a a o o

3 w a w OG w w c~ ~ a p a

COUGH

SPUTUM

~ ~ JJ

SUBSTERNAL SORENES S

OR AWARENESS

y ~

SORE THROA T

(or HOARSENESS) S ~ ~j ~ ) I

SHORTNESS OF BREATH

NASAL DISCHARGE /

CONGESTION 1

WHEEZING /o

CHEST TIGHTNESS /

RESTRICTION

FATIGUE /c,

HEADACH E

FRONTAL : NO \

/

, YES

EYE IRRITATION

OTHER SYMPTOMS

(LIST )

I l ( ( c}-r i. ', ~~ 1

If symptoms & dzscomPqrt A-igl ~

lasted several hours,

would they c aus e yau to : v

(Refer to A-H )

A . Decrease optional or recreational activity List

B . Take additional medicatio n

C . Be unable to perform the maximum amount of work that you could normally

perform

D . Turn this workload level down(disregard fatigue )

E . Be unable to perform your usual work* activity or level of productivity

(* occupation, schoolwork, critical househo ld duties )

F . Stay at home sick(lose sick time from work)

G . Visit your physicia n

H . Visit an emergency room
GL:OtTP

l

-SUBJECT NO .

DATE

r

o w c~ ~

H

!iJ -~~-

a H H H H W a

H H z z

COND .

0 3 H

w

~ ~ H w o w w w H H a

a

a

z x z m m H cn H k a x SCORING p a H . H H H H H W r . V

1=NONE 20=MODERATE F W O x x H H x H z E,

5 !;tTZACE 30=SEVERE w a: c7 w m W m w v~ o w m Cr

10=MILD 4 O=INCAP . w x '' x W x w x w a x o C

3 w x w x w x w ac ~ a a

COUGH

SPUTUM 1 + /

SUBSTERNAL SORENES S

OR AWARENES

T S SORE THROA

(Or- HOARSENESS

OF BREAT ) SHORTNESS H

NASAL DISCHARGE/

CONGESTION

WHEEZING -5 "

CHEST TIGHTNESS/ ~-- t ~ ; I -~ • / ~ ~~ ~~ ~ ,~

RESTRICTION 1 `l

FATIGUE

HEADACHE ~l

FRONTAL :- NO L--" YES

EYE IRRI fATIO N

OTHER SYMPTOMS I l 1 1 1 t +

(LIST )

? f symptoms- & dzs-comPo.r:t

lasted several hours, ~,~ I'► ,~~ C/

would they, cause- you to :

(Refer to A-H) C6

A . Decrease optional or recreational activity Lis

. Take additional medicatio n t B

C . Be unable to perform the maximum amount of work that you could normally

perform

D . Turn this workload level down(disregard fatigue )

E . Be unable to perform your usual work * activity or level of productivity

(* occupation, schoolwork, critical househo ld duties )

F . Stay at home sick(lose sick time from work)

G . Visit your physicia n

H . Visit an emergency room
GFiOUP W

. Z •✓~

SUBJECT N0 .

DATE

H H c~ `

H H z W L

L' 0 ND . a 3 H H H H 1-

" H W O W W W H f-~ a4 Q

SCORING a a z oo M H M H x ¢ x

pr ,7 H . H H H H H W ~. V C

1='NONE 20=MODERATE F'

5$T~ACE 30=SEVERE w ao, n w ~ Cl) w Cl) o w ~ c

10=MILD 40=IRCAP . x w x w x w a x o ~

3 w x w x w cz W x a c. a

COUGH

SPUTUM

SUBSTERNAL SORENES S

OR

/ ( <

OR AWARENESS

SORE THROAT

( or HOARSENESS) f ~ ( l ( ! ~ / ~ ~ r ,

~' (I

SHORTNESS OF BREATH

NASAL DISCHARGE /

CONGESTION

C

/v

WHEEZING

CHEST TIGHTNESS /

RESTRICTION JD

FATIGUE

HEADACHE

FRONTAL : N0 . YES

EYE IRRITATION

OTHER SYMPTOMS

( LIST )

Lf symptoms- & dis•comfq.r:t ~C

lasted several hours, ,

would they cause-you to :

(Refer to

/ i

A . Decrease optional or recreational activity List 1

'

B . Take additional medication V &

C . Be unable to perform the maximum amount of work that you could normally

perform

D . Turn this workload level dovn(disregard fatigue )

E . Be unable to perform your usual work* activity or level of productivity

.(* occupation, schoolwork, critical househo ld duties )

F . Stay at home sick(lose sick time from work)

G . Visit your phy sicia n

H . Visit an emergency room
GROUP 1

~

8

ptiJ ~,

SUBJECT NO . ~~`

357 DATE E 4

C OND . ~ 0 3 H H N w a

H w o w w w H

vc x z a~ x

► -~ a Q <

SCORING A4 H H H H w x, ~ C

1=NONE 20=MODERATE ~ E' ~

S *T,.RACE 30=SEVERE ~ ~ w

0 0 0

C.0 v~i oz

E

t

10=MILD k0=INCAP . w x ~-+ x w >e x a c~ o c 3 w x w r~ ra x w rz = a.

H w COUG

SPUTUM 1 .

SUBSTERNAL-SORENES S

OR AWARENES S

SORE THROAT i

(or- HOARSENESS)

1

SHORTNESS OF BREATH

NASAL DISCHARGE/

CONGESTION

WHEEZING / ( ~ / ( `~ ~ ✓ `

CHEST TIGHTNESS /

RESTRICTION

FATIGUE

IV ~ J

HEADACHE

FRONTAL : NO YES

EYE IRRITATION

-

( \ 1

~ OTHER SYMPTOMS

( LIST)

1-f symptoms- , & dis-comfQ .r,t

lasted seve ral hours,, ~

would the

(Refer to

y

A

cause

- H

- you to : / r

A . Decrease optional or recreational activity List '

B . Take additional medicatio n

C . Be unable to perform the maximum -amount of work that you could normally

perform

D . Turn this workload level down(disregard fatigue )

E . Be unable to perform your usual work* activity or level of productivity

(* occupation, schoolwork, critical househo ld duties )

F . Stay at home sick(lose sick time from work)v

G . Visit your physicia n

H . Visit an emergency room
GF:OUP

SUBJECT N O

DATE l ~ ~( 1 1S ~ o w ~t

EA

H H

F"'~ C7 C7 z L

- a H H H H W a

z z w

COND .

.0 3 H a a

1

H w o w w w H F-1 a

SCORING

a~ z fA V] H CA H }C a x

a , a H . H H H H H W x• U

1=NONE 20=MODERATE cc

o x x E F E' ° UE-+ z E, o E

5 ~tT.RACE 30=SEVERE w w o w M w co w cc o CC

10=MILD kO=INCAP .

W x x w >e w >e w w a o

3 w x w a w a w a ~ a a

COUG H

SPUTUM

SUBSTERNAL SORENESS

OR AWARENES S

SORE THROAT

(or HOARSENESS) ` ~I I ( ~ ~

/ , ( < < I

SHORTNESS-OF BREATH ~ ( 1 L)

NASAL DISCHARGE/ ~ I C ~ I

CONGESTIO N

WHEEZING

CHEST TIGHTNESS/

RESTRICTION ~ ~ \~ J J ( ( I

FATIGUE

FRONTALE:-NOZYES_

EYE IRRITATION

OTHER SYMPTOMS

(LIST ) ~ Li

1-f symptoms- & dzs-comfq•r.t

/

lasted several hours- ,

would they cause- you to : (

(Refer to A-H

/1

A . Decrease optional or recreational activity Lis t

B . Take additional medicatio n

C . Be unable to perform the maximum amount of work that you could normally

perform

D . Turn this workload level down(disregard fatigue )

E . Be unable to perform your usual work* activity or level of productivity

( * occupation, schoolwork, critical househo ld duties )

F . Stay at home sick(lose sick time from work)

G . Visit your physicia n

H . Visit an emergency room
G30,UP p. 8

• SUBJECT NO .

DATE ~l I~~''-~!I J o w,

E H f.

.~ Z C7

COND . 7~ w a

H w o w w w H H a ¢

SCORING a x z cn 03 M ><

H H H H Gr] x_ V C 1=NONE 20=MODERATE rn E' ~ ri

5*T~ACE 30=SEVERE w~ G w M w cEo Cl) oz w c~i~

10=MILD kO=INCAP . w

X x w ye w ye w a a o

It w x w cr w a w a o a, a

COUGH

SPUTUM J ~

SUBSTERNAL SORENESS . %

OR AWARENES S

SORE THROAT

I l /

(or HOARSENESS )

SHORTNESS-OF BREATH ~ ~lJ l ` ~ 1 1 7

NASAL DISCHARGE /

CONGESTION

WHEEZING C,

, -

CHEST TIGHTNESS /

RESTRICTION

A ~ ~~ ` ~: ~ ~ ~ ,_, • ,.

FATIGUE ` ± •

I

HEADACHE

FRONTAL : ft0 YES

EYE IRRITATION

OTHER SYMPTOMS

(LIST )

Lf symptoms- & dis•comfQ•r:t

~

laste.d several hours

would they cause-you to : ~ 9G ~ ~C ~ ;~ ~J (. \

(Refer to A- H

A . Decrease optional or recreational activity List .1

B . Take additional medication (J ,

C . Be unable to perform the maximum amount of work that you could normally

perform

D . Turn this workload level down(disregard fatigue )

E . Be unable to perform your usual work* activity or level of productivity

(* occupation, schoolwork, critical househo id duties )

F . Stay at home sick(lose sick time from work)

G . Visit your physicia n

H . Visit an emergency room
• ° GROUP '~'~ ~ ~~ L $

• (' ~ ~ l~ y3

SUBJECT NO .

DATE o

E~ H C' H H Z

COND . /~ a H H H H

O 3

~ H w o w w w H f-I a Q c

SCORING x x z cn U1 F.., M x ¢ x _

a+ `J H H H H H H

1=NONE 20=MODERATE C13 E' 0 U v

r - V C

t S C )

5=TRACE 30=SEVERE w

.o x x F E• H z F

CC. w M m cn o w cc cr

10=MILD 40=INCAP .

W x '-' x w x w x w a x

3 w x w cz w c~ w a ~ w a.

COUGH Ij/ 1 `~l~ 1 ~~ ~ ~ ,~ ~`~ ✓ ?

SPUTUM

SUBSTERNAL SORENESS ~~ / T T k

OR AWARENESS io

SORE THROAT

( or HOARSENESS )

SHORTNESS OF BREATH 10 /10 ~

/

NASAL DISCHARGE /

CONGESTION Z-)

WHEEZING

CHEST TIGHTNESS/

RESTRICTION

FATIGUE

HEADACHE

FRONTAL : NO ►►► /// YES (~ ! ~ J ✓ ~ ~~ I

EYE IRRITATION /

S 0 OTHER SYMPTOM

(LIST)

Lf symptoms- & dzscomPQ.r .

hours-, t lasted several ►

would they cause you

(Refer to -A-f

to : CIp. ~

A . Decrease optional or recreational activity List

B . Take additional medicatio n

C . Be unable to perform the maximum amount of work that you could normally

perform

D . Turn this workload level down(disregard fatigue )

E . Be unable to perform your usual work* activity or level of productivity

(* occupation, schoolwork, critical househo id duties )

F . Stay at home sick(lose sick time from work)

G . Visit your physicia n

H . Visit an emergency room
p.82

. _. . .. . - . .

. --_. _ - - ------- - ------__--___-- - ------1~-- ~~

, GROUP C1 .~f✓ j , ~ / v/ ~

SUBJECT NO . c~ •~ //'

DATE J I " o w~~ W

H H U n z F

C

H H Z Z w L'

COND . a H H H H w

H w o w w w H H a

a 0 3 H a

a

SCORING a a z m rn H m H >e ¢ -

Q. ~ H H H H H H W x, U

1=NONE 20=MODERATE F' 0 n ~ a

se o ~ a e• E• H Z E.

5=T71ACE 30=SEVERE w c: n w cn m w co o W n c

10=MILD kO=INCAP .

PQ x H x w X w se W x o c

3 w x w oc W x w x

COUGH

SPUTUM ' / ~ `j ~ C~ ./. . • ~

SUBSTERNAL SORENES S

OR AWARENESS

SORE THROAT

(or HOARSENESS)

/3

SHORTNES$ OF BREATH

NASAL DISCHARGE/

CONGESTIO

H~EZI N 7

CHEST TIGH ESS /

(

~?~~STRIC ON '~~

FATIGUE z

HEADACHE

FRONTAL : NO YES

EYE IRRITATION l ~

OTHER SYMPTOM S

(LIST) f _

Lf symptoms & dzs•comfor.t n~C 41() ~ !~

lasted several hours- ,

would they cause

(Refer to

- you to

- -- ~

: l ( (

A . Decrease optional or recreational activity Lis t

B . Take additional medicationC . Be unable to perform the maximum amount of work that you .could normally

perform

D . Turn this workload level down(disregard fatigue )

E . Be unable to perform your usual work * activity or level of productivity

(* occupation, schoolwork, critical househo id duties )

F . Stay at home sick(lose sick time from work)y

G . V isit your physicia n

H . Visit an emergency room
GRGUP

SUBJECT N0 .

DATE 41

n

L

E-+ H C7 C7 x z

H H z z w w

`~ (~ H H H H w ~..a COND . o ~ H a a

H w o w w w H H ~

a

.] a a

SCORING LL ~ H H H H H H w x

z `o '••'' X a x

: V U

1=NONE 20=MODERATE W E•'

5=TRACE 30=SEVERE cs

Se o x a E

: o w cn w

4 E

ca

-4 E-4

w ca

z E+

o w cn M

10=MILD 40=INCAP . w

X '-' ye x se w a. rs o o a:

3 w oc w a w cr. w x ~ w a a Cr_

COUGH

SPUTUM sS~SS 5- :

SUBSTERNAL SORENESS /

OR AWARENESS 7;1

SORE THROAT

(or HOARSENESS)

• SHORTNESS BR ATH

/

NASAL DISCHARGE /

CONGESTION

-WHEEZING `~

CHEST TIGHTNESS/ r /

ES-T R I c I o $ / G~ ! ~ ✓ ~~ C/ ~ ,~ '=a ✓

FATIGUE

HEADACHE

FRONTAL : NO YES ~

EYE IRRITATION

OTHER SYMPTOMS

(LIST) l % I \ 1

?f symptoms-- & dzs•comfo•r .t C'2r.;L

lasted several hours,

would they cause-you to : J (((/

(Refer to A- H

A . Decrease ontional or recreational activity List

B . Take additional medicatio n

C . Be unable to perform the maximum amount of work that You. could normally

nerform

D . Turn this workload level down ( disregard fatigue )

E . Be unable to perform your usual work* activity or level of produc t ivity

(* occupation, schoolwork, critical househo ld duties )

F . Stay at home sick(lose sick time from wor k )v

G . Visit your physicia n

H . Visit an emergency room
~

GROU. ? 1 ~~ i j ,i ~ ~ J J

SUBJECT NO .

DATE 4 o w o r

• H

COND . H~

H w o w w w H H

~ ~i H H H W a a O

a a a

SCORING L~+ ~ H H H H H H W x• U U

z v~ a a a co H cn H se a x x

i

1=NONE 20=MODERATE w F' ~ U c~ c, c

5=TRACE 30=SEVERE w no

W X '' x w x w x w a a o o a

. 0 w cH w c~n o ~ a

10=MILD 40=INCAP .

a w x w x a w a ~ a a a ~ w

COUGH

SPUTUM

SUBSTERNAL SORENES S

OR AWARENESS 1

L5

~ f7 S ~ ~//~ l0 ~1r7

SORE THROA T

( o'r HOARSENESS) ' a 1d 4

. A9 /0

SHORTNESS OF BREATH )0 /

&7, ~O b

0

j

~

NASAL DItCHARGE /

CONGESTION / -

'/ 0

2-:FC-EZa~ 1 5 -0 (~ ~b b J° /D ~`

CHEST TI dHTNESS/

/ STR~;C JION

FATIGU E

HEADACHE

FRONTAL : NO YES l 1(

EYE IRRITATION

OTHER SYMPTOM

(LIST) l

S

If symptoms- & dzs•comfo•r .t ~ %~ 4p~ J90 ,l(~ 1'J(1~' 0 ~fL

lasted several hours•, Y~ W

would they cause- you to :

(Refer to A- H

A . Decrease optional or recreational activity List

B . Take additional medicatio n

C . Be unable to perform the maximum amount of work that you.could nor ally

perform

D . Turn this workload level down(disregard fatigue )

E . Be unable to perform your usual work* activity or level of productivity

(* occupation, schoolwork, critical househo ld duties )

F . Stay at home sick(lose sick time from work)

G . Visit your physician

H . Visit an emergency room
p. 8

GROUP 1 ~ J ~I hj) '"Z

,~-

SUBJECT NO

~~ I~- ~f1J . DATE H

w

~ H H z z w G~

. H c~ ~ z z

COND . x H H H H w a a

Hw 0 w w w H H a a ¢

a

SCORING Q~ H H H H H H W

a`x z v~ m H cn E-+ x ¢ x x

. . V U

1=NONE 20=MODERATE Eq 0

E., a H a E, z " E, e• a

5=TRACE 30=SEVERE rw,a, ~ w ca ca w co 0 ca cn ~

10=MI~,D 4 O=INCAP . /3 w z w a w a w a ~ °, a a P . v

COUGH

SPUTUM

SUBSTERNAL SORENESS ~

/

~

OR AWARENESS t\ l

SORE THROAT

10

/

(or HOARSENESS )

S 0ATNESS OF I~g REATH O

L

7

c, w-~ lll " 7-0

NASAL DISCHARGE/

CONGESTION

EEZIN - L W) 1 2

CHEST TIGHTNESS/

RESTRICTION- 76 Zo 20 0 16 1/0

FATIGUE I ~ 1 I l l/ l ~

HEADACHE

FRONTAL : NO YES

EYE IRRITATION 1

OTHER SYMPTOMS k ~ I ~ ~ ' / ( r )

( LIST) Il /

I_f symptoms-- & d=s-comPor:t /~l> C

lasted several hours,,

would they cause- you to : I C

(Refer to A-$

A . Decrease optional or recreational activity List

B . Take additional medicatio n

C . Be unable to perform the maximum amount of work that you .could normally

perform

D . Turn this workload level down(disregard fatigue )

E . Be unable to perform your usual work* activity or level of productivity

(* occupation, schoolwork, critical househo id duties )

F . Stay at home sick(lose sick time from work)

G . Visit your physician

H . Visit an emergency room
p. 86

GROUP

(~ (1

SUBJECT NO . !1 i1 y ------

- /

, w w

. DATE -

E-4 H c~ v z z

~ H H z Z w F7

COND . . J o a H a a

ac H H H H w ,~ a .

H w o ' w w W H H a ¢

a

a

SCORING x a z u~ cn H rr~ H x ¢ -- x

_ 13. ~ H H H H H H W 0U

1=NONE 20=MODERATE x o x a E+ a E+ aa F z ~ H e+ a

5=2';RACE 30=SEVERE w rs: r~ w M w co w co o w v~ m~-

10=MILD 4 O=INCAP . :3: w a~c w z w a w a ~ a. a

P.

COUGH D

SPUTUM I I J S Z~

SUBSTERNAL SORENES S

OR AWARENESS I 0

J rJ f~ ~/ ~

0

O

SORE THROAT + (V / /

(or HOARSENESS) I ( ' f~ '0 )0.

S 7

O

OR,TIES~ 0~' BRE TH J O 1 ~ l U/ O~a

.Y>"~ l / 0

NASAL DISCHARGE /

CONGESTION 6- ' 6

WHEEZING I D 1 S

10 /'o

CHEST TIGHTNESS/

RESTRICTION (/ /0

FATIGUE ~~~ 5 lo I D~ s~ ~~ S

HEADACHE /D ~ ' I I / J J f,

FRONTAL : NO YES ( I / / / /

EYE IRRITATIO N

OTHER SYMPTOMS

(LIST)

If symptoms-- & dzs•comPo-r.t t~c Ia b • ~~G Y 6

lasted several hours- ,

Would they cause you to :

(Refer to A-H

.A . Decrease optional or recreati nal activity List

B . ^ake additional medicatio n

C . Be unable to perform the maximum amount of work that you. could normally

perform

D . Turn this workload level down(disregard fatigue )

B . Be unable to perform your usual work* activity or level of productivity

(* occupation, schoolwork, critical househo '_d duties )

F . Stay at home sick(lose sick time from work )

G . Vi.sit your physicia n

H . Visit an emergency room
GROUP p $ ~, ~- ; ~~

SUBJECT

DATE

NO . !~ /\4

7~ ' w w

E+

H H

► -+ c~ • c~ z z'

z z w r4

COND . 0 3 e• a a

H H H w a

H W O W W W H H. ~-1 a d

~Y. a m (A H fA H _a x ~

SCORING

z x

. a, a H . H H H H H W U U

1=NONE 20=MODERATE y d o x E.,, a E, a E,., z

5=T; tACE 30=SEVERE w W. c~ w to w co w ca 0 W ca cc

10=MILD 40=INCAP

. w x w w x o o a'

3 w a w x w x w x ~ w a a crCOUGH

SPUTUM 1 1 I I ► ~

SUBSTERNAZ SORENES S

OR AWARENESS )al

SORE THROA T

(or HOARSENESS )

c O'~SHORTNESS OF BREATH 20 ~ / 6 / ~5 l a 5 ~ :k✓ ~

NASAL DISCHARGE/ ~ D ~ ~ ~ ~ I I ~ 1 '•

CONGESTION / 0

4HEEZING Zd 1 , J 1 ) ~ I

CHEST TIGHTNESS /

RESTRICT O N

~ L ✓✓ ,

FATIGUE

HEADACHE

FRONTAL : NO YES

EYE IRRITATION l I ~ ~ ~ II

1

OTHER SYMPTOMS I ) I ~ I ( ' I (~~

(LIST) l I

If symptoms• ' & dis-comfor,t

lasted several hours-,

would they cause- you to : y

(Refer to A- $

A . Decrease optional or recreational activity List

B . Take additional medicatio n

C . Be unable to perform the maximum amount of work that you. could normally

perform

D . Turn this workload level down(disregard fatigue )

E . Be unable to perform your usual work* activity or level of productivity

(* occupation, schoolwork, critical househo_id duties )

F . Stay at home sick(lose sick time from work)

G . Visit your physicia n

H . Visit an emergency room
• . . GROUP $$

SUBJECT NO .

DATE E

H H

H oo z z.

z

COND . o ~ H ~-+ H H W a a

H W 0 W W W H H a a

SCORING z x

p+ U H H H H H H W „+„ • U U

1=NONE 20=MODERATE E'

SG O ^~ cz E+

5=TRACE 30=SEVERE E H E4 cc w rs: ~ w cn w m w m o w

10 MILD 40=INCAP . w x H ye w x w x w w x o o P.

~ w x w x w x w x ~ a a a• cr_

COUGH ' ~ ✓ ~ ~ ~ ~ / / ) I ~ j

SPUTUM /0 I~( S~~ ~ ~~ I b S

SUBSTERNAL SORENES S

OR AWARENESS

SORE THROAT

(or HOARSENESS)

SHORTNESS OF BREATH lI~ ~ 20 IZP- 1 6

NASAL DISCHARGE /

CONGESTION 10 (0

/

6

, 1(9 /o ~

S

WHEEZING

12

CHEST TIGHTNESS y

RESTRICTIO N

FATIGUE 1 ) l . / ) l ~ ~

HEADACHE i

FRONTAL : NO YES

EYE IRRITATION

OTHER SYMPTOMS

(LIST )

Lf symptoms- & dis•comPo.rt ~Q~

lasted several hours. ,

would they cause you to :

(Refer to A-H )

, A . Decrease optional or recreational activity List

B . Take additional medicatio n

C . Be unable to perform the maximum amount of work that you. could normally

D erform

D . Turn this workload level down(disregard fatigue )

E . Be unable to perform your usual work* activity or level of productivit y

(* occupation, schoolwork, critical househo ld duties )

F . Stay at home sick(lose sick time from work)v

v . Visit your physicia n

H . Visit an emergency room
GFtO"JP ~,,t ' . 89

j

SUBJECT NO

. • . --

I

( P

DATE

H H U, ~ z z

w

COND . 0 3 H H iHr H W a a

H w o w w w H FH..~ a ,

.a a

SCORING a~ z H H H H v~ t~ y~ ¢ ~ x

1=NONE 20=MODERATE H

5=T'RACE 30=SEVERE W. 0

E-1 U U CE., E-+

10=MI tD 4 O=INCAP . w X '' x w w w ~ o o a a w a w x w a w rx ~ Q, H

44 Q,

C oUGH

SPUTUM ,'-

~ 170 -/

SUBSTERNAL SORENES S

OR AWARENESS

V

SORE THROAT

(or HOARSENESS)

/

(/

~ I 1 ~ ~ ~/j J J+n J/, ~ /~

1 v I ( l/ /( I /

7

SHORTNESS OF BREATH

lol / ~? 2

~'~ ~O

)

%

0

NASAL DISCHARGE/

I v = CJ 1 I. J

CONGESTION /0 'jj{1

WHEE6I{N~G /1~0

101-1 _10 20 10 11

CHEST TIGHTNESS /

RESTRICTION (0 I )

0

'

0

C~

FATIGUE

HEADACHE

FRONTAL : NO YES ~ . I 1 l I ~ ~ I ~ ~

EYE IRRITATION • ~ ~ f I + I j

I ) I ~

111 I

OTHER SYMPTOMS

(LIST ) , ~ ( •~

?f symptoms & discomfort

iL

lasted several hours•

- you , would they cause to •

(Refer t o

A . Decrease optional or recreational activity List

B . Take additional medicatio n

C . Be unable to perform the maximum amount of work that you. could normally perform

D, Turn this workload level down(disregard fatigue )

E . Be unable to perform your usual work* activity or level of productivity

( * occupation, schoolwork, critical househo ld duties )

F Stay a t home sick(lose sick time from work)

G . Vi.sit your physicia n

H . Visit an emergency room
-.0U=

S?,B .-ECT NO . V-7

DATE

~- E" H ~ ~ z

H H

z

W4

COND .

0 :3-

H H H ~ a a a

W 0 W W W H H

SCORING a ~ Z H

CO

H H H H H (c

U) M ><

a

1=NONE 20=MODERATE

x 0 rz Eco F' 0 U C

4 X E-f a E+ z E., 5=TRACE 30=SEVERE w w C w Cr. W CO W co 0 W co W ~

10=MILD 4 O=INCAP . w x ~' x W a w w r~ w a

r4 X W X W P.0

:D a ~, a o

COUGH f I 1 _~-- ~ -

►

~

SPUTUM

SUBSTERNAL SORENESS

OR AWARENES S

SORE THROAT J

( or HOARSENESS) )0 j ~ l s / s s

SHORTNESS OF BREATH S 1 1 D / ~ S l~ ~~ s -~

NASAL DISCHARGE /

CONGESTION

WHEEZING

CHEST TIGHTNESS/

RESTRICTION

FATIGUE /O 5 ~ •I 1 ~ ~ / / j ~

HEADACHE

FRONTAL : NO YES ~ ( I

EYE IRRITATIO N

OTHER SYMPTOMS

(LIST)

symptoms & discomfor t

.sted several hours, ~-- - _ ---

)uld they cause y%ou to :

Zefer to A-Ii )

A . Decrease optional or recreational activity List

B . Take additional medicatio n

C . Be unable to perform the maximum amount of work that you could normally

perform

D . Turn this workload level down(disregard fatigue )

E . Be unable to perform your usual work * activity or level of productivity

(* occupation, schoolwork, critical househo ld duties )

F . Stay at home sick(lose sick time from work)

G . Visit your physicia n

H . Visit an emergency room
SiTB

. I ~

.TEC'r NO .

DATE w w

~70

/ F H o ~ c; c

COND . 0 3 ~ ,~ ,~ H u w w, 4

H w o w w w H ~ a a a H a SCORING a a z co ~ ,~ co H X Q ¢

a

:D H

1=NONE 20=MODERATE Cl) E-' 0

c H H~ H

C

5=TRACE 30=SEVERE w a c7 w E-4

W

& W ~ o F E-' ~

10=MILD 40=INCAP .

W X '-' X w x w X ca a a co co

3 w c~ w a w a w a ~ a Q wc

COUGH ~.-

SPUTUM

SUBSTERNAL SORENESS

OR AWARENESS

~, -

SORE THROAT ~

(or HOARSENESS )

SHORTNESS OF BREATH

i

NASAL DISCHARGE /

CONGESTION

WHEEZIN G

r 1

CHEST TIGHTNESS /

RESTRICTION ,,-~

I ) ~_

FATIGU E

HEADACHE i 1 r ~

FRONTAL : NO . .~ YES l I ~ J f ~ ~ r r

EYE IRRITATIO N

OTHER SYMPTOMS

symptoms & discomfor t

_sted several hours, ~ . / ~ ~ ~ ~ C C C C Cl-

: uld they cause you to :

.efer to A-A )

k . Decrease optional or recreational activity List

3 . Take additional medicatio n

. Be unable to perform the maximum amount of work that you could normally

perform

D . Turn this workload level down(disregard fatigue )

E . Be unable to perform your usual work* activity or level of productivity

( * occupation, schoolwork, critical househo id duties )

. Stay at home sick(lose sick time from work)

3 . Visit your physicia n

i . Visit an emergency room
.92

SU3 T ~~T' No . ~"! Z ! (~'~

DATE

~ C 7 C:

E-4 H

U Z z

H' H

COND . ~

G~ H H H ~ z ~; L'+

o w E

w ,a a

w w H H'

SCORING ~ x z ca CO H cn H X

a a H

l=NONE 2'0=MODERATE M F' 0

5=`"RACE 30=SEVERE r-Y-i a; 0 c--a~ m r4 m w CO o CO cEn ~

10= M ILD 40=INCAP .

C4

.~

x x w x G= a. cG o o a . w a w cc w ~ w x ] a ~,, a cr_

COUG H

SPUTUM

✓ 5 ~ ~ ~ !

SUBSTERNAL SORENES S

OR AWARENESS 0

SORE THROAT / I

( or HOARSENESS)

SHORTNESS OF BREATH

I ~

~G ~~ /~ S S S

NASAL DISCHARGE /

CONGESTION /r ~ /v ~ D J c

WHEEZING

1 -30 z

O

~'o Za 0 /0 / l sv

CHEST TIGHTNESS /

RESTRICTION 2,0 ~O

FATIGUE 5

EiEADACHE

FRONTAL : NO YES_I,/

EYE IRRITATIO N

OTHER SYMPTOMS

( LIST)

symptoms & discomfort

sted several hours,

ild they cause you to :

-a fer to A-g )

. Decrease optional or recreational activity List

. Take additional medicatio n

Be unable to perform the maximum amount of work that you could normally

perform

Turn this workload level down(disregard fatigue )

Be unable to perform your usual work* activity or level of productivity

( * occupation, schoolwork, critical househo ld duties )

`ay at home sick(lose sick time from wor k )

' t your physicia n

an emergency room
SUS,-E qT NO .

DATE ! Z_

E- y GU C ~ ?

COND . Z cr y rH, H z z ~ ~z

o ,y ►~ G=, a a

H r.-7 O f~ ~I L a y r4 $4

SCORING a a z ca Co M y X ~4

1=NONE 20=MODERATE Q =

c

c

H E, E0 U U U C5=TRACE 30=SEVERE wX H X u u ~ c-- r4 C12 o ~ ~

co 10=MILD 40=INCAP . a W ~ w ~ a a ~ rr o c ~

COUGH ~ ~ I ~ •~ ~~ ~ i o 0

SPUTUM '

SUBSTERNAL SORENES S

OR AWARENESS 5

% V \l

SORE THROAT

(or HOARSENESS)

SHORTNESS OF BREATH

NASAL DISCHARGE /

CONGESTION

2

WHEEZING

r U , z ~ Z 0 icl) f` O 2~ ;~o 'zo nb ~ ~i 1 G

CHEST TIGHTNESS /

RESTRICTION f ~ O ~O O

C)

FATIGUE / 0

HEADACHE

FRONTAL : NO YES L,-~ I I

EYE IRRITATIO N

OTHER (LISTYMPTOMS

symptoms

(LIST)

- & discomfor .t

~ I

sted several hours, i

uld they cause you to :

efer to A-g )

Decrease optional or recreational activity List

Take additional medicatio n

. Be unable to perform the maximum amount of work that you could normally

perform

Turn this workload level down(disregard fatigue )

Be unable to perform your usual work* activity or level of productivity

({ occupation, schoolwork, critical househo ld duties )

. Stay at home sick(lose sick time from work)

. Visit your physicia n

Visit an emergency room
SUBJECT NO . 9

` D-°-TE_

F . H o z zc ~

COND .

,L--- 0 3 H H c= , a ,a

H ca o w

SCORING a ~ z H H rn cri H

1=NONE 20=MODERATE Cn c~ 0

H H H w ~

U U C

0

5=TRACE 30=SEVERE w a ~ w ~ CC

0z

co

o

10=MILD 40=INCAP . ~'' x '-' x w X w ~ w a co

3w x w r~ w rr w x a Qo, a U

COUGH /1 0 -5 0

SPUTUM

SUBSTERNAL SORENES S

OR AWARENESS /7

SORE THROA T

(or HOARSENESS)

1-5

SHORTNESS OF BREATH ;;7C~

NASAL DISCHARGE/ _ I

CONGESTION /v

WHEEZIN G

CHEST TIGHTNESS/ /

RESTRICTIO N

FATIGUE

HEADACHE

FRONTAL : NO YES

EYE IRRITATIO N

OTHER SYMPTOMS r ( ( ( ~ / / /

(LIST) 1 IJ \

symptoms & discomfort

sted several hours ,

sld they cause you to

efer to A-g

: G ~L

)

Decrease optional or recreational activity List

. Take additional medic atio n

. Be unable to perform the maximum amount of work that you could normally

perform

• Turn this workload level down(disregard fatigue )

• Be unable to perform your usual work * activity or level of productivity

(* occupation, schoolwork, critical househo ld duties )

• Stay at home sick(lose sick time from work)

• Visit your physicia n

Visit an emergency room
SUBJECT N O .

DATE J

tA I

~ c ~ c<~

J

~ ti z z z

COND .

o r4 ~4 Et-i W O W W W H '"" `-' SCORING a a z

co a '""' vi <

1=NONE

5=TRACE 30=SEVERE

20=MODERATE C

r4 a, a r

, cc r4

F' x E' z r10=MILD 40=INCAP . W x x W X r4. "

a a a' co

3 w x r4 rz W ~ ~, a o c c

COUG H

SPUTUM

SUBSTERNAL SORENESS 1

OR AWARENES S

SORE THROAT

(or HOARSENESS)

SHORTNESS OF BREATH

NASAL DISCHARGE/

CONGESTION

WHEEZING

CHEST TIGHTNESS/

RESTRICTION

FATIGU E

FRONTAL E NO : YES

EYE IRRITATION

OTHER SYMPTOMS

(LIST )

symptoms & discomfort

sted several hours,

uld they cause you to :

efer to A-ET).

Decrease optional or recreational activity List

3 . Take additional medicatio n

Be unable to perform the maximum amount of work that you could normally

perform

~ . Turn this workload level down(disregard fatigue )

Be unable to perform your usual work* activity or level of productivity

occupation, schoolwork, critical househo id duties )

Stay at home sick(lose sick time from work)y

Vi.sit your physicia n

. Visit an emergency room
f i~ .9

S.UBJEC T

DATE

NO WA

. . P4. G:

COND . 0

z z z

SCORING

H O L+

a a z

co

G7 W H H F~j ¢ C

m ► -+ cn H y~ .

1=NONE 20=MODERATE co aE_' 0 ~ H ci H c' v " c

5=TRACE 30=SEVERE r--x-~ c 0 E- C. cEn c-. m c-a= M oz E' ~'

10=MILD 40=INCAP .

r4

3 f-7 z L 7 t~ G x '-' x r4 X W.7 ~ f-7 c~ p . x o c

. p p. c

COUG

H SPUTUM ~ • l ~/ '~j ~ I / ~ ( I

SUBSTERNAL SORENES S

OR AWARENES S

SORE THROAT J f

(or HOARSENESS )

SHORTNESS OF BREAT

H NASAL DISCHARGE/ ✓ ~\ ~

CONGESTION '~

WHEEZIN G

CHEST TIGHTNESS/

RESTRICTION

FATIGU E

HEADACHE

FRONTAL : NO - YES

EYE IRRITATION J v

OTHER SYMPTOM

S symptoms& discomfor t

sted several hours, r I

ild they cause you to :

°fer to A-H).

. Decrease optional or recreational activity List

. Take additional medicatio n

. Be unable to perform the maximum amount of work that you could normally

perfor m

. Turn this workload level down(disregard fatigue )

. Be unable to perform your usual work* activity or level of productivity

({ occupation, schoolwork, critical househo ld duties )

. Stay at home sick(lose sick time from workr

. Visit your physicia n

Visit an emergency room
~ - /

Sut rEcT NO .

41

DATE 2 6

'J~

E H L-_ C

COND . S cr ~, F~ ~' z z

H

F-! G=7 O

SCORING a c~ z m m ,~ ~ _<

1=NONE 20=MODERATE x o H ~ "U '

5=TRACE 30=SEVERE r=a a; ~ ~ o

PEI.

E- r

10=MILD 4 O=INCAP . x '-' 3~7 cz W (n ""

~ CG Cx7 0 p ~O c

COUGH

~ ' JC/ ~ ( c ► ~ - / ,

SPUTUM

1/0

SUBSTERNAL SORENES S

OR AWARENESS ~ l L~

7-C)

SORE THROAT /

(or HOARSENESS)

SHORTNESS OF BREATH ZC. /0 ~~ /L C2

NASAL DISCHARGE /

CONGESTION -5 0 C

WHEEZING Z(')

CHEST TIGHTNESS/ .

RESTRICTION

0 ;to

FATIGUE

HEADACHE

FRONTAL : NO YES ✓ ~ I b

if5

EYE IRRITATIO N

OTHER SYMPTOM

(LIST) I

S

symptoms & discomfox .t "8 4

sted several hours ,

ild they

_fer to 'A-H

cause

)

you to : A C C

. Decrease optional or recreational activity List

. Take additional medicatio n

. Be unable to perform the maximum amount of work that you could normally

perform

. Turn this workload level down(disregard fatigue )

. Be unable to perform your usual work* activity or level of productivity

( * occupation, schoolwork, critical househo ld duties )

. Stay at home sick(lose sick time from wor!; r

Visit your physicia n

Visit an eme :-gency room
.98

• • . r - - -9 I ' • ~ ~~ -

.

. -- -

.

i '

~ q UBJECT NO . .-10V

DATE

` ~ E-H G-, ~; c^

O H H H H W L+

v c3 z

COND .

0 W W W H r

E-1

., a a SCORING z

02 M

1=NONE 20=MODERATE

► 0

0 0 0

U C

5=TRACE 30=SE VERE W p, ~ W ~

co w ~ z E., E-+ a

10=MILD ~+O=INCAP . 3 cXa a ~ ~ ~ a w ~ ~

0

oc o o~ ~

a, a Cr

COUG H

SPUTUM

SUBSTERNAL SORENESS )

OR AWARENES S

SORE THROAT

(or HOARSENESS)

SHORTNESS OF BREATH

NASAL DISCHARGE/ I

CONGESTION

J I

WHEEZING

CHEST TIGHTNESS/

RESTRICTION

FATIGU E

HEADACHE

FRONTAL : NO YE I ~ ~ I 1 S

EYE IRRITATION I ~ I ~ I

OTHER SYMPTOMS

(LIST)

symptoms & discomfor.t

sted several hours ,

uld they cause you to :

efer to A-g) -

l . Decrease optional or recreational activity List

3 . Take additional medicatio n

: . Be unable to perform the maximum amount of work that you could normally

perform

) . Turn this workload level doun(disregard fatigue )

Be unable to perform your usual work* activity or level of productivit y

occupation, schoolwork, critical household duties )

Stay at home sick(lose sick time from : ro rk )v

Visi t your physicia n

Visit an em e r'~en (' :- roor.
P

. _ 9 ~ . . .

. _ --- ;

$UBdLCT NO .

DATE a ~ a w

E

COND . 0 3 H H H H W ~ a z z z z

+ H W 0 W W W H H

~4 a d

SCORING ca co ►-+ co H X a a_

a+ H H H H H H (-~ ~ ~J

1=NONE 20=MODERATE E''

5=TRACE 30=SEVERE wc0 E-4

0 0 C

W coo E E~

10=MILD 40=INCAP . W x ~' x W x W x w a. a

co

3 w c~ w ac w c~ w a ~ a o~

. a P . c

COUGH

n

(V 16)

SPUTUM

n l -D 1,5

SUBSTERNAL SORENES S

OR AWARENESS

SORE THROAT

(or HOARSENESS)

SHORTNESS OF BREATH

NASAL DISCHARGE /

CONGESTION I l J > I ~ / ~- ? ~

WHEEZING

CHEST TIGHTNESS/

RESTRICTION

FATIGUE

HEADACHE

FRONTAL : NO YES ;

EYE IRRITATION

OTHER SYMPTOMS

(LIST )

L symptoms & discomfor .t

ssted several hours,

D uld they cause you to :

3efer t o

A . Decrease optional or recreational activity List i C( ,' 1

B . Take additional medicatio n

C . Be unable to perform the maximum amount of work that you could normally

perform

D . Turn this workload level down(disregard fatigue )

E . Be unable to perform your usual work* activity or level of productivity

( * occupation, schoolwork, critical househo ld duties )

F . Stay at home sick(lose sick time from work)

G . Visit your physicia n

H . Visit an emergency room
S_ OBJECT' NO . L0G~

DATE 11 l9 $~ o

E H G i C; C

COND . Z~N-x~ =JPJ a H H H z z c-z, c~~

o 3

H w o w L=i w F F a '

►~ w ,~ ~:

; r'

H

SCORING p.

M c

H H x

a

o

_Q

1=NONE 20=MODERATE cO 0 o

H P_

~

U C

5=TRACE 30=SEVERE w c ~ ~ Cn M z E, E10= MILD ~+O=INCAP .

C4 X '-H w x w x no.

3 w ~ W ct

r4 co o~

r=1 f~ w a U G. P., P. cr,

COUGH

SPUTUM

I

SUBSTEgNAL SORENES S

OR AWARENES S

SORE THROAT V

(or HOARSENESS )

SHORTNESS OF BREATH

NASAL DISCHARGE/

CONGESTION

1

WHEEZING

CHEST TIGHTNESS/

RESTRICTION

lz5

FATIGUE ~ f~ lD ~ l ~ ~O J~

HEADACH E

FRONTAL : NO YES

EYE IRRITATION

OTHER SYMPTOMS

(LIST )

symptoms-& discomfort

.sted several hours,

uld they cause you to :

efer to A-g )

ik . Decrease optional or recreational activity List

13 . Take additional medicatio n

Be unable to perform the maximum amount of work that you could normally

perform

D . Turn this workload level down(disregard fatigue )

Be unable to perform your usual work* activity or level of productivity

occupation, schoolwork, critical househo ld duties )

Stay at home sick(lose sick time from work)

Visit your physicia n

Visit an emergency room