W a w ~• z o P
. ~ • w o H A o~G w N a w A d 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 U ~ o~r~o UU H H w w .a xd z >+ 0~ w P . H~n O w 5d x A A o a H N oG o P4 0 0 En 'JI P : ~ W>t 6~ ~ O gl~ W C~ WH HW vt cn o 0 z d W a 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 ~

Z d Y~ N~ H W p,' H W c•'1 N d ~n V) 0o a ax w aHV) P-1

W r~ W w ocn w ~ w > a x ¢ w w a a w .G W a H PL . H H to 0 oE/) U .Z Sa w cn > H > ► -i t+
. U .G ~ F-~ [--~ 0 v1 N W ~ ~ U W~ W WW ' u PQ O O 21 "J A A w W C> 60 d O H 0 W H W w C4 C 4 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 fe c J Jl J yY )C Jl )~ )S ~' )c 1 1 ) s 3 S' All f 7S 4 Ll-J VJ / U~/ VS l 41 4 N 04 W vl vl z W w' ~G W O 0 U f ~ Z H cQ W vUi H zH z d W x d (14 0 W C/) ? H ~ ~ O H O a a' H t(n ]q 0 Z 0 F-4 ~ H x a; Lf) W ~ W W' ~ H w' w z H ~+ N H ~ Q H cs', q W o0 W C~ aW : Z W Wcn r~ 0 > P, III F4 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 -ItE 2 HOUR POST 2 HOUR POST 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 P OSTN ~ E4 

## 914 

# T w ^ ' a w A°° a p .2 ~ ' ~ I x w wd a}+vl C o -3 Hz H cn F PQ W A H En v -4 V U U a O tn E ~ 3 k . Hd] Z Z O 0 .- V L .+ O D U H H W W ,.f oG d Z >+

~ >+ v O W H N PG 0 A ° L O a W w r a x w cn O U W O~- +

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

# S 1 -

(y 

# ~ ~ y' d ~>+a H W ~ ~ Lc] <'~l N Q [N cn ~ • w ~ Z co cu c~ a a ] H cn ~ E ~+ oG v~ Cil x H>+ > a4 [il w' W W O .-] V] m _ P \ a0 W CL H ., a~ ¢ Hd W O ap En u d Z H O[n Z\ P w N > cn > W W U cp w a Z z . w -' w U w c~ w x O • x [ .~ H H x E . W , U A A w "~ w C9 O(9 O' C9 O' C9 O H U a Cl ) w W Y C ~ 0 ~ U v a NO w a a w U cn W ~ 5C ~ ~ w ° O w Fd-. wwx rl~ 04 x w~x xOulOx w ~ Y ~ c, U oG p A k. A [.. A c= . A k . Z n x 3 x w ~ ~ U k+ Q 2 1 ~ 

# ppF : :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~ U ) w ~ ~ U) z `Q w c°~ ¢ z ~ H 0
~ U H A ~ ~ O d ~ W cn 0 H ~ ~ i ~ 0 C~ r-I r I U H H o ~ ~ H Z' H H r,' ~ ~ F-4 0 5 pf-a; U W n0 x W C~ ~ • zW W Z W Cn H5 6 ~ n W : 0 : :D En 0 a4 =3 0 t/] C ~ U a : cn ~ QH a U Cl) tn v) cv°) c°n aA 'Z ~ ~ C~d ~C W O 

### S 

# h WEEK PRIOR ON EiITRY 4 1 ON ENT RY IN CH

### A MBER 5 

### 1 +1 IN CHAMBE R ON EXITING ~ ~ 5 1 I - ON EXI TING 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

'4 rtS 00 _ •~ • W O H w' W o W L.3 - O?G >+ P. • tn ~-] W A H n am w oL U W¢ ~+ cn C a ,...~ H Z cn ~ ~ w O W ~ A H v ~ U U c¢i O~ ~ ~ L H z H a z z O ~ H c ~

U 0 ~ OcL D dU H H W W a r~ d Z ;>4 W >+ >' W P . H cn O W z1 x A A O CL H N r] : co vP; O A ~ A rA~ cn O~ W ~ A C~ C9 H H ~4 pO A ~G >G W W H R, a F-4 ~ tn 0 U u') W A H Ct) OU (n d x 3 w' w' 3 H O v~i r4 3 ~ x vw i

v

T x x cn ¢ ~ ~
~ ~ w ~ a'aH" ' o a cn w ww xH¢ w w a .~w ~''¢o H a~ H

Q [-. w o t H ~ ~ k~ w' H W ~ tn ~ H > H U[, Z 1-14 z Z H 0 H Z E n U w U W OW W w' 0 O~C

a A w W C~ O C~ O c~ O C~ O H U a pNj H F . c~ L

. H W Cl) . U H w ~o ~ UUa ~ wa ty a wU v~ W r d~ r ~{ , ~ YG a d O W H 04 a a w O rn . 10 0 N U u w A k . A C-4 A [•, A C.. Z n 7C 3 x ~ ~ ~ U 

# , Sg, 5r„z 2 1 (~ r t i7 il c t i >1 sC ~t ~i ~f J` lc 7t ls 3 3' i~ ~ 7t 4~ ~r Yi ) vJ vs ! 41 4 • s t Sf
cu ~ En z 04 ~ x a~ ~ CQ 

# U3 w w 

# 0 d~ ~ H H H `° ~w a' w H r' z d w x d J H ~ ~ ZO d W 

# M p; 

# 0 C~ ~-' • W W O E -Hr ~ ~ tn ]Hd z H H m -3 U P4 04 w C1 z ~ a~ aiw~w w `n H ¢~ ~ D a ww~cnw0 a a0o o ~ H N Ln c~ U r~ tn ¢ :D U cn rn W cn ( n c~. 

### WEEK PRIOR ON ENTRY O N ENTRY IN CHAMBER 5 `~ ~ ~ ID 5 ~~ I IN CHAMBER ON EXITING ~ 

# 4 5 --ON EXITI N G 1 IIOUR POST - 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 2n' ,~ . tt : w p W • W O H

w c~w ~ z o ~D p

. 4 l .7 -' • W M A O 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) p 6G Z 0 ~ H (~ W U O l+ . O D U H H W W ..] W . d Z CI& >4 r W W H v7 O W ~7 x A A O P. . H N oG O c>~ O . a n ~ ~ A cn O W 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 H o U) a to
{~ ., v X U)l d >4 N A H W W c'1 N d tN (n W I Z c~ m cu w w w .a H cn w ~j ~ H>+ W w w' W W O .-7 U) w W cn \ 00 W > P, x H d W W .-7 .-l W d O

w .• O cHn > c Hi7 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
. 6 Z no 0 V V A A W a ty ~ W U SG cn W W O W H O aG ~ W W p: c>~ w' w a5 w' w w O v~ O x W W H H \ r~ H Ln En U U w' t> ; A tx~ A tL A w A [ . Z n x 3 x ~ v tv d



# 2 3 s L IF, 17 a /' a) tt 1 YY l A u > t if 7 il lt 3 1 514,13 7113 VL .i~ 4l i Of Vj l 41 4 - S 2 SS
d' w In W c~i7 Z
0 PQ W U H~ • d 7 z i f z d w x d F-4 (n F 4 ~+ O d • W v7 0 0 C.~ 1-+ W H H Z O H w' H~ k / 7 ] x Z Z H x c~ r u a H rx W O C4 x ~ z H y+ cHi H ~ d H u O ''t :D A U W M W C .7 W z W cn H 0 -~c m cl, ~ :) z n.' cn ~ C~ ~ Ri V7 ~ Q 5 U 04 ti7 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 O N EXI TING 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 POSTp . 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,62 7 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 4 4 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 .22 I • .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 .I7 0 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 61 1 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 16 4 /,131 e,672 6 .666 6 .• 6 .2 3 6 2 .616 2 . 4 4/ / 226 /,122 6,197 / 061



### C-2 4 R163/ACC W

### P- - ~ v~~y

GROUP 

# -TL SUBJECT N0 . DATE ~ E- F, F~- z z z COND . . F- w o w w w - ~ ¢ z cn cn ~ rn x ¢ SCORING 0 . : 11 H , F w U 1=NONE 20=MODERATE F ' o z c~ E c~ E ~ E
- z E 5=`I`jRACE 30=SEVERE w e . : w cr~ m w cc o G cc 10=MI L D 4 0=Ii4CAP . ~` '-' x x w x 

### a w rz w c~ w ~ w c n a. ~± J CouGH ` I SPUTU M 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 perfor m 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 w E- H U U z H H z z w COND . a F+ ~- H H w a 0 3 E- a a H w o w W w H H a Q H x a z 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 OUG H
SPUTUM 1 - • ~ L' ~~~ /O /~ SUBSTERNAL SORENESS J v ( ~ / OR AWARENESS / ~ I I SORE THROA T (or HOARSENESS ) SHORTNESS OF BREATH ~ ! r NASAL DISCHA R GE/ ~ I CONGESTIO N
WHEEZING CHEST TIGHTNESS / RESTRICTIO N
FATIGUE f I I I l ' i HEADACH E FRONTAL : NO YES ~
EY E ~IRRITATION 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 z H H z z w 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 x a~ 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 COUG H
SPUTUM SUBSTERNAL SORENESS I ~ ~ OR AWARENES S SORE THROA T ( or HOARSENESS) / J I (
SHORTNESS OF BREAT H NASAL DISCHARGE/ ~ I I l CONGESTION l



# f ,

_ WHEEZING CHEST TIGHTNESS / RESTRICTIO

N
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 perfor m 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 ) Ircm 7 4

. . Sta at home s_c's ;lose sick e C . Vis'_ oc~ fsicia :

._ c •r 7 ~cmP . 9 ~ ~77

GROUP 

### lr SUBJECT NO . DATE ~~ ~ il ~ 5 a w E r CD 0 z H H z z W COND . a H H H H ca ,~ r O 3 N H W O W W W H H a 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 + J SUBSTERNAL SORENES S OR AWARENESS J I I I ~ / i SORE THROA T (or HOARSENESS) ~ ~ 1 I
SHORTNESS OF BREAT H 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 y ou_ 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 perfor m 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 wor .-)~ yc

- _ ~ s

_ . .~ a n E
. a_ S ~„ ." .-- e - ^`' - :'oo'^P
.

GROU P SUBJECT NO . DATE F H ~ F- H z z w F-i w a COND . o 3 E a 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 BREAT H NASAL DISCHARGE/ + ( j CONGESTION I( I . / _ WHEEZIN G CHEST TIGHTNESS/ I I RESTRICTION ~ - 

# 1 I l J~
FATIGU E HEADACH E FRONTAL : NO YES j I ~ 1 ` ,ll /
EYE Y~ 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 w crK that you could ^ormall ;;' perfor m 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 - o Sa at home sick( cse s_ . .~ _--e _--__ -- - yourP .

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/ CONGESTION 

### _ 9J WHEEZING CHEST T~GfiT'_4iSS/ RESTRICTION ~ ~ --- - ` . FATIGUE 

# 1 I HEADACH E FRONTAL : NO YES J l I '
I I ~ EYE IRRITATION I I I OTHER SYMPTOM

S (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_°cr m D . Turn this workload level down(d'sregarc e / C . Be u n 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

GROU P SUBJECT NO . 

# T
DATE W

. . [~ - H C7 C .7 z



# 3 • H H z z t~ ; COND . H H w ~ O 3 H W O W W W H H w7 E SCORING a cc z cn cr H x Qr .-^ 7- H H 1- F•-y H !-~7 U 1=NONE 20=MODERATE c o 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 

## l I ~ I 1~ l~ COUGH 

### / SPUTUM ~ I SUBSTERNAL SORENES S OR AWARENES S SORE THROAT ( r , ~ L (or HOARSENESS) I ! ~_ J 

# 1j SHORTNESS OF BREAT H NASAL DISCHARGE / CONGESTION jo Q ( O ID / WHEEZING ~ I 1 CHEST TIGHTNESS / RESTRICTION
FATIGUE z I , HEADACH E FRONTAL : NO YES 

# 1 ► l f 

# ~ EYE IRRITATIO N OTHER SYMPTOM S (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 d perfor m
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 -_ 2 _ . 7

_ : a13

GROU P SUBJECT NO . DATE F H ~ c~ z H H z z w a ~-+ H H H Gz~ a 

### COND . 0 3 E- , `a a H W O W W W H H ~7 SCORING a a z ~ u~ F~ u~ ~ x a z a,-~ 1- H H H H H Cx7 1=NONE H

20=MODERATE co E' S=TRACE 30=SEVERE w c~ ~ w c Er co

E 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 ., COUG H SPU T UM I ~ I SUBSTERNAL SORENES S OR AWARENESS / I I J ) ` f I I SORE THROA T (or HOARSENESS) l . J SHORTNESS OF BREAT H 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 

# ~3
c c z ~ H H Z Z w COND . z H H H a -~ ~ 0 H w 0 w w ~ = ¢ < u= Cn SCORI N G !1 ~ H H H H H - U C 1=NONE 20=MODERATE x o X; 5=T'RACE 30=SEVERE w c~ C) CC a u~ w 011 0 w c~ u w x F, x w x w x o C 10=MILD 4O=1 VCAP . 3 w a w cc w cr w z ~ w a COUGH
SPUTUM SUBSTERNAL SORENESS OR AWARENESS 1 + SORE THROA T (or HOARSENESS)
, SHORTNESS OF BREAT H 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 GROU P SUBJECT NO . DATE~ o F 

### C4 z < H U 0 ~ H H z z a COND . ~ H H H H w ` O 3 E- a H w o w SCORING ~ a z C° 

### co co x ¢ a 

### =) H H 1=NONE 20=MODERATE CC E'' o z rz E - X E
- cc E• z ~ 5=T;RACE 30=SEVERE w a : c:) w Cl] W CO w cn c 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 BREAT H NASAL DISCHARGE/ t f ( t ~ ~ I II CONGESTION ~, 

# 1 I I I 

### `~ ~ ~/ ~ •~~A / WHEEZING

, CHEST TIGHTNESS/

_ ~ -) RESTRICTION' Z
FATIGU E HEADACH E FRONTAL : NO YE S 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 ~ 'I

• A- f 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

GROU P SUBJECT NO .- , DATE ~ o y W ~W, c

",` c' H U C7 Z

i H H Z z W COND . 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 BREAT H NASAL DISCHARGE / CONGESTION (I
WHEEZING I ~ CHEST TIGHTNESS / RESTRICTION" t ~ " ✓ ~ ~ FATIGU E HEADACHE FRONTAL : NO YES ( l
EYE IRRITATION ~ ~ l I ~ l ( OTHER SYMPTOMS I ~ l ~ (LIST) J 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 roomp .17

GROUP V' 

# G SUBJECT NO . DATE o w ~ E H C' L COND . 0 3 ► d H H C H cJ w a ~
~ a a H W o W W W H H a ¢ SCORING ~ ~ z ~ ~ ~- cn H x ¢ a~ H ~ .{ H H H H e~ - c~ 1=NONE 20=MODERATE CC F x E~ E7 5=`P ~RACL 30=SEVERE w D~ c W ~ Ga 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
COUG H
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
WHEEZIN G 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 roomGROUP

SUBJECT NO . DATE r H c~ c ~ / H z z w I 7 H t-~ ~-+ H w ~ COND
. 0 3 F a ~ H w o w w w H ~ _ a (L fL z CI] H H x a S COgZNG co M w ~ H t+ H H H H w U 1=NONE 20=MODERATE E' ~e o - rz E- 4 E-+ cc E
- z E-c 5= 7RACE 30=SEVERE w~ v w cc w m ca cn o w ~n L w x H w x w x w a 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 THROA T (or HOARSENESS )
SHORTNESS OF BREAT H 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 roomGiROUP

SUBJECT NO . DATE o w c ~ E+ H C7 U z H H Z Z W COND . H H ~+ H w a ~ O 3 E-i a a «-+ w o w w w H H a a_ ` CG C~ Z m CA co 7C SCORING ,.., , w U l=NONE 20=MODERATE ~e o a E- ~ Ea 5=`P jRACE 30=SEVERE wct-. v w CO w co cc 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 j z NASAL DISCHARGE / CONGESTION I I I
I , I I WHEEZING 

# 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 perfor m 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 roomGROUP

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 co Ew cEc w cEn o w c~n U 10=MILD 4 0=INCAP . w X r' >` w x w x w a o C w a w rz w ~ w a a a . COUGH SPUTUM lC~~~ l l I



# ~ I I 1 I 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
-X F.EZiiV G 

### (CII5 T, J
FATIGUE

~ HEADACH E FRONTAL : NO YES
EYE IRRITATION OTHER SYMPTOMS (LIST ) If symptoms & dis-comPor .t lasted several hour a , w ould the y 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 w cr'-k )y G . Visi~ your physicia n H . Visit an emergency room /~21

GROU P SUBJECT NO . DATE E '' - - - --- _. '- z z w COND
. - 0 3 w a 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 ~ ~ HEADACH E FRONTAL : NO YES J I EiE IRRITATIO N OTHER SYMPTOMS (LIST) f Symptcros & discomfor t 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 W w c~ o E' ~--~ c7 ~ z z H ~-+ z z w w COND . !~ H H H H W a a o a w o w w w , H 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 roomLGROU 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 e+ a a a H w w w w H H a ¢ d 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~ o m 5=T~RACE 30=SEVERE w~ w M w ~ w m oz W co M N H 10=MILD 4 0=INCAP . W x x x x w a c~ o o a a w rz w rz w cz w ~ ~ a a a co COUG H
SPUTUM SUBSTERNA L
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 1 RESTRICTION V FATIGU E HEADACH E FRONTAL : NO YE S
EYE IRRITATION I I I I ~ r ~ ~( I OTHER SYMPTOM S (LIST ) symptoms & discomfort 

# A' A 74-C, C 4 C iasted several hours, ~~ would they cause you to : ` Z (Refer to A- H A . Decrease ootional or recreational activity List d,zl f , ia B . Take additional medication amount of work that you could normally C . Be unable to perform the maximu m 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 room2 GRjUP • _ ,

~ ./~ SUBJECT NO . J I DATE o w c~ E
- ~, o c~ z z ~ H r+ z a w 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'i RACE 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)

I I ~ ✓ 1 ~ SPUTU M SUBSTERNA
L SORE THROAT ~ I I I I f I I J ~ (or- HOARSENESS )
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 

# 1 I !~ I ; ~ 1 1 l~1 EYE IRRITATIO N OTHER SYMPTOM S (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 perfor m 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 roomp•
SUBJECT N0 . U

l

- DATE 

# [,4 !~' \ 0 E+ H c~ c~ z z ~ H H Z z COND . a H H H H W a a o N a a ¢ H w o w w w H LL' a+ H a

Z U] H U~ H Q

U~ H H H H H W U U SCORING ( 1 . a H X 1=NONE 20=MODERATE U2 E' 5e o 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 o a 3 W rz w cc w x W cc ~ a a . a . cr .
COUG H
SPUTUM SUBSTERNAL SORENESS 1 C/ OR AWARENES S 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 YE S
EYE IRRITATION ` OTHER SYMPTOMS I I ( ( 1 J J I ) (LIST) ~ } I I If symptoms & dzs-comf p r.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 perfor m 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 ) )v F . Stay at home sick(lose sick time from 'wor k G . Visit your physicia n H . Visit an emergency room

# p~,

GROU P SUBJECT NO . 

# `' DATE ° w 0 E• H U U z ~ lH H z z w COND . ✓ ~ ~' H H H H W a a

o s N 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 M E ' ~e o rs F F cz F z ~ E c~ 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 f ~ I x 0 OR AWARENESS " SORE THROA T (or HOARSENESS)
SHORTNESS OF BREATH NASAL DISCHARGE/ CONGESTIO N
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 SYMPTOM S (LIST) 1 1 ?f symptoms & dis- comfor t 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 perfor m 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 ) )v F . Stay at home sick(lose sick time from wor k 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 w H H y y [z] a COND . a H H H H W , . .a a o ~ E-4 .~ a a H w o w w w H H 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 co Eoz w co E 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/ /~ CJ CONGESTION a 

# o 1 (~ 

# 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 IRRITATIO N 

### 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 L is t B . Take additional medication ~ C . Be unable to perform the maximum amount of work that Y ou could normally perfor m 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 h ome sick(lose sick time from wo•-k)v G . Visit your physicia n H . Visit an emergency room. 28

-

GROU ? SUBJECT NO . DATE 0 E-4 -+ U U z z ~' H H z z w a COND . A H H H H W a a 0 a H a a ¢ H W 0 w W W H H a ¢ CG p'- . z m H U] H ¢ .SCORING m x a a H H H H H H w ~ CJ U 1=NONE 20=MODERATE co c Se 0 + ~ E• G . 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 a a w c~ w rz w ~ w a ~ a a a U COUG H 

# SPUTUM ~ !D ~~~ l 0 IC 1 c' IC' SUBSTERNAL SORENES S OR AWARENESS SORE THROA T (or HOARSENESS) I 1
SHORTNESS OF BREAT H 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

~ 1 !' ~ 1~ i l I i EYE IRRITATION ~ ~ I I I r I ~ 1 I 1 OTHE R ( SYMPTOM S LIST' J ~ Lf symptoms& dis-comPQr . t lasted several hours, Would the y 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~ perfor m 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' 0 E, a 1NO SC o - rz C_ Cr E-4 z E 5`I ;RACE 30=SEVERE rs : c7 w W w n w co 0 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

' ~ ~ ~CJ J C O UG H 

# o / 0
SPUTUM l D ! D l v l l~ ~~ D ~/ J~ ~ ~V ~D SUBSTERNAL SORENES S OR AWAR E NESS ( ( ( SORE THROA T (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 YE S
EYE IRRITATION OTHER SYMPTOMS (LIST ) =f symptoms & discomPpr .t 

# A asted several hours , v ould they cause you to : (Refer to A- H A . Decrease optional or recreational activity list O~~rC~Se

~ It Laff B . Take additional medicatio n C . Be unable to perform the maximum amount of work that you could normally perfor m 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 d uties ) F . Stay at home sick(lose sick time from work )V G . Vi .sit your phys_cia : H . Visit an emergency roomp . 30 Zd T) - - - = - =



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

-- 

## == 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
OftS S 0= 3~ ^

_ T . 

## c~~


# .,T C

R C 

# - o -I

# v 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 :or a u :-a this c :orklOZd 1~~,rCl QOr.rntQ=sr°~garQ L? Jd~1C 3c' uClZOi° to D?' 7 - OtS your llsilz l 3C t 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 .3 1

. _-_-_ ~~ ~~ " ~ ~ ✓ ~~~ ~~ ~ / / • 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 C_JCtI C . J



### ---- 4



### _. - :T 

### 1

~ 

### 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-- ° c a c.^ : ~0UG 3 

### 3 RUTU 

### M S 17

### B S?'ERN4 

### L SORENESS 

# t±_ ± ) R 'S J 

### 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

# .vG HEST TTGn^'_1 -

" SS / E STR T C'nl0iv ` ✓ ~ !( ` ✓ 1 

# -_~ TCIUE 

# 1,j 1 

# () 10 ZC~ 10 l~ IC~ lU EADA

# CLLE 1515 

# 5-15 S ~ 1 5-1 ONTnL : NO 

# Y YaS
`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 cro QucL1`%1 z .1 ~ l ocC 1 r 2 t i oCl , sc hool : :o r'~c, C_' : ti C 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 

# - r-- -_- ~ C ~vT i7 = = - `-- _ -_ c 

### ? = .aov1 20=_0 DE_R ^_^ r_ cr C-) C-) = U i=-°yC 3 0 =jCY~ G7 = CJI 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 E OR"-''Y E SJ Or 3 LD =^ -q } , I ~ ~ ) ! ~ I ^_Sa D~SC12r E j 

# ,~ ►

-

# s - 

# ~mr~ ; N ES S



# _

-

# _ C 

# ~~
x j 

# o<< J c~ ► ~ c~ ~ c~ t ~ 1~ o NT

# ~~J N

# O YJS ~ 10 /0 

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

~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_ " , L to D e _ = 0 T' il VC l2 = u 5
- c C C Oc c O(1 s c `l00 L . :Or_ 7
- . . L o e c T ` r • _ S

_

### p . 34

- =

_ C

# _ ~ - - ~ QND 

# . - - _ -

GPP >C ,1C- 

### _ 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 :S J

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 

### 7- El Z 

# 1 I ~

-Z T 

## - S T 7



## _ e S^C" ! 0_v l 

# T T C: 

# J ~ A

# ~ A C H OYTn-LJ N

0 77a S v-Xj''O MS

~ 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 Q O 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 

## . G R P r = c_ G= ~~ •= CC C o SCOR! VG r ; H r . x ¢ C - 1_`?OY E 20= M OD E R A T .L Q E- 0 Ei C-) z E- 

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

# I ► 1 1~' `~ ~ S- S`~ or HOARSENESS ) HOR`"ivE SS OR BR R1`
- F i t l l ~ ~ ) A SAL DISCHARGE / ONGr .STIO N

HEEZ

# Lv G HEST TIG H TNESS/ ~ ~ 1 1 1 ~ ~ ~ i ) 1

~ STR_C`"IO V 

# ^~ `~

# J
~- ~ _' 

# ,_ DAC

# II E ;ONTiL : NO Y E S
'S IRRIT A TION
3". 'R S l

[!vfPT ~~ ~ ( LIST C 

# ~

, ~toms & aiscom_o .- e d several hours, ~--~ - -- -- - i they cause you to : -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= 

### j O 

### m 2~=-- :D-?_`- 

### T- E 5=TRACE 3 O= 

### 3 G T! 

### E

_ . 

### E 10=111D 

## Lo=__~rC AP 0 X 

## ;< 

# r C

# O



# ~PU

# =U 

# u > > I ~ i Su 

### 3 2 

### T z' 

### R as,- 

### SORENES S OR AT

__RE _'d E ti S SORE THROA T 

## ( o ; H

## op a

## S E 

## :r Z 

## SS ) ( ~ 1 S



## _CE 

## .,,r E 

## s S OF 

## S~`- 

# ~ r

-- --

W

# -~~~ IU G 

## _v_ ! _CnTo ~,r E SS I 

# -'-`=== VE 

# c 1 ~ . 1 1 ~ HEADACH E : R O W _-_L : VO YE S


### 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 perfor m 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 

### v or_' .{ 

### 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 O = ^ SCO R - :~T C

~ ~ = . ; 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 G - 

## 0?ve E 

## S T 

## _p N 

## ~ ) ~ ► ' I ~ 1 i )



# ~~ E 7- 7- 

# I~: G 

# I ~ ~ + C HI EST T=G~

;TN EQ S / ~ST~ CTTpV i ! f ! l l 1 i 1 ) I

AD pC HI E '~OYT A -T : V0

\ `! 7 S
I R RITA TION )

# T EHER 

# S rXPT

# p M S ( D 1 J T~ 1 I S ymotoms & di=ccra_o . - 0 g C


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

# j 1 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,'Or l 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 w or'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 =,_ C' Sr~ J C r _ _-- v U U C '

= 

### '7-H 1_Cl

. 

### 3 Q

_ 

### S G 'J

~" L'~ 

### _*7 "

0 _' = ~ • r-- 

### : ' C

U (-_'t U] r_- = - U] u7 O C G~ - 10=',rrr, D L0=! :1C ,~ ° . CQ CO

# U G H Sp

# UT um 

# IT I JU3S T=

. R !11i, S7~ :f S J 0 R A ;Y n

A P t'V : .` l'J 1 I I I, I ~ ~I ~ j S OR E THROA T (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

~ ✓ En D 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 perfor m Turn this vor!cload le v el doun(disregard iati g ue ) e unaD l e 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 

# 7 11 0 it 

### D
°-_C 0 G=Si_- D ' ~=__v ~l r f I _ X ~' X n ^ ! C = G7 1 : .



### ---------------- c 0

# U G 

# ~ I , ~ I 1 ~Um~~ Su3s?~3 ^=

AN 

# ~ 

# I 1 I ~ ~ I s (arfH o :r~~~ ) 1 

# i~, r ~ 1 l l 

# ~ I ►

- 1 . 5 yG 

### ~T G : .S~ 01 r / + 

# I

H- T



### -:7


# _ C

# ,_y-y

r .n . _7

# J_~=;,.r_~-~u;

_ - . I se're- =ao ' 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 t , do ~(d s e~==a ' ) 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 -- C L7 G7 . G ; - x ~ C C 

# S C- 

# C-

cr~, 2'J= n0 a

_ _ a 

### 5 - C ~ 

### 3 0= 

### S L Y 

### t-: C_
. - ~ _ L CI] r^---. ~Il C - _ LC=! .r 7 T .0 ~C=__vC~_? . Y x C O (IC q-

~~~4i-JVSC :'.~~i_J : . 7 - 

# I ~ ~ I I ~ I s~

So 

## ~~ m ~a=~ 

## ) I I 

# 0= 3 a :

# -'_r

_ D 

# S cc- 

# ~~ c0?iG 

### Z
. ST-Oiy



# _ : c
0 

### ' I 1 

# - - -- ~~ I ► ~ I ~~

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 ¢ :C a - 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 . B e ~~Il¢2C__ 

### 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 _ r _ - - !=WYE 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 _"- 

### a C 

### E / CO 

### N G 

### W T=O_y 

# ~ ~ : .: V

# =l ZZ 

# - ~ l ~ ~ ~ > > r ( ~~ WEST m 

### T (' _-

# - ~~ : ._ _ 

# ~ ~~' 

# ~ {1 , - - --

_ ~


# =v . =C _r ~ -

# = : 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 o er to

A _ n 

### ) 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 

### T, I ( m ) ~ ~ ~ ~
~ I I S J^~ 0[IlS ~ Q1 s CCI1 :Cr .L - - - - - - ~eQ 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 z cn c~ r cc f x a ti' F r - 1=_1ONE 20=,_OJER_^ '-'_ c : C o 

### 5=-'-RACE 30=Sr .V L°E - cn co cn o e Cl) c : C-' X H r - ~ , 1 0 ='~T L D LO=~NC~° . X c COUG H 

### S?

# UTUM 

# ~ ; 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 TN

### E SS /



### D A C~ E iONT-^-_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- ;'~ : _ _ .. . ~3 yourp . .4Wi~ ;-~ .'4R_'a ;

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

i -• -- - -- -- -

. . . . . ...,~ . . ° --- - . .. . . , "
. . ~

' . . . I ' : . . . .

~ . . ~ . ~ t .

~ 1 1

. . . . . . . . - i - . . . - -
. ._- _ _ . . -

- . 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 ^ ~ _~ :< c ` c

- Cm
. 

## C~ cre _ 5 5 5 `~ ~j 

# (5 

# 15 I~) 5

J 2J"-'J ZX- .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 ISCZ

# s= GE

# / COYGES= :OY 10 +~? I V I~ ~~ M / 0 VEEZ

# . ; .,G WEST _T-GEY'~Z,~ - / 

# f _-- _-_ T



# __ .= 1 f ; l 1 ~ 

# _r`

_ " :o YT

## -=-- Y e 

## -~ ~ 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 B e 

### G 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- ^ ^

~ c

# ~D 

# . ~ 1 -i?0 N E

. 2 0 =- : 0 D3`__ c ; = c ; `- - - - c 2 C . r--

~ C~ 0 = 5 1 :

.. .- . ~ ? = .__ ~, D C=vC .__ X COUG ~ S 2 U'" U

# M S F

. 5 0 R 

# = , Q 

# ~ SO R7 TE 30-_ ^ 

# ca E

# o~_ 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 '

-_ -' --•- =-~--= 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 ad d_ '_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 A m EE /
CD Alp r _ - }= C < 5 :.0 R =YG CO x

- `ION~ 2 0 ='fOD`- i Cr c= c c c c E- C C c CrI 1 r1=.'.T > < ~- ~- Cr: c y C r f G 

# C OU 

# G H 

# ci
rQ"_'TJ M 3U--- ST E3^t

-

-"- 1 S O ?

. E .r E sS OR oiv=~= -',

r ETS S jOK~ i~~On m (or 

### HOARSENESS) ( , I ( 1 J 

# C5
S cOR 

# . r, 

# ~~

_ 

# m _~I SJ 

### OF ER, `,_ - 

## y A sar. D I scLLs F

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

~~ . -, ZiiIG S~~~~Gp y N 

### E SS/

-7C-U 7 

# C ~

_ = CV :^

# L No 

# ~ l i 1 ~ 1 I= 

### R r`rn_"' ; O 

### N T ~ 

### E'i S'L'r~^0MS ~~~~ l ~ ✓ ~ I I ~ ~ _rr~~toms & disccra=c : .L f Q~ e= se rer_1 hours, 

# 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 _ t 

### 10 us ° . ^ _ o 

### L ~ Gu 

### 1~ d u t i e s )

_ 

### S Stay at ho 

### rm

_ V _v c u- p^ 3

_ : . .

### p . 48 

# rt-

_ 2

:,

C~ Y C =tilQ 

### L2 (3 CI ; _- C _ c _ _ CJ C 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 

### s s

~v

# R m

# N !' .SJ 

# OF CJ 

# 5 1 S

1 

# 0 Y

## ~c~s D 

## ov A

## ^c / 1 0 

# ~~e E Z 7 

# :JC: 

# 5 I ~ ( ~ l ~ i!(~m m, C: =-~{JJ/ r 1 I ~ / I 1~n ~ ~ 10 15



## ~ s `?-"-_~ : 

# NO

r 

### ^



## ~ 7) 

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

### a ? aou~-s , ~ C 

# t

~ ~ 

# 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 

### r kload ° 

### 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 - I - - f - 

## C 

# O crc_ 

# :7

# ) 'rJ

J

# W `T Ji f 

# s US 

# :• EMA

# = s M



# _ MSS 

# ` ! ► ~ ! ` ~ ! , l ~ ~ OR 

## =-w 

## =-=-= :t = S 

## s (o~ E 

## ~o~,~_r E 

## ; ) -1 1 

## ~ I l
5 

### E 01`"_, 

### ZSS OF ~ ._~__~ l {! 1 f~ I ~ I ► NASA L 

### CO

# _zG



# _ S 

# __a :~ ~ O 10 10 

# iD f I ~ c~~ E 

# : ,, f

# ~ S 

# :. / :=5 =°=C ==0_y



# __

__ 

### AD -- ''^

- I \ l \ 

### Z 

# p NT 

# , I 

# : vo



# -.~- ~==-r.~- .• ti ~ I ~~ ~ ~ ~~1 .

S

# =,.r= ~ CME 

# I R 1
l 1iJ='~ ` ,

.. 2 = S e 'r? _' ' - hours J If~ , 1 1t "Y

, 1
- 'I

1 ~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 V J _ . . 

### t . . ._ 

### l you COU-G : O_- D 

### o rCO r 

### m P 

### Tura t :'_S 40r 

### t 1 03G 1 

### 1 Y 

### I _ i jT Be l27?_O 

### L _ CO C?- ;0 :~ . your usual V O :' :C1 ZC t _Y_` O" 1_'T_? O : D["OG'1C = j r ' ~ t O C C - 7 = 

### t _ C Z C - - _ - -- - 10LL5

- 

### n L

- 

### d '1 : ~ - - 5 1

1 

### n L C 

### so E - - - ` Cr:,J 

# 10

- 

# C

~ 

# 0

• L / / ,~ t ~ _ D ` M cc 

# ~__ - - - ~C < < SC~_~-_YG C- C G~ > < 1 = jO i E 20 =--~~- R '---

_ _ _ ~__~_--C _

~ ,0=

## s c ~~ 

## az C c Cn CC 10-VELD

- G
. .,- 

# COUGH c~2 

# ~ s s 5 5 ~
SP

# JmU 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 

# __;. DMO

# u__ aGE/ 

# ~b 5 5 Cor;c Z

## S T 

## =o t

i

CE

# _ ST 

# T_ G

# _- yES RES 

## - R 

## _C T 

## _o_y 

# -=----J E



# _ ,_Y 

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

# _ '-'A-_ _Y _r C ,~- ` ~I 1 `I I I ~ ~ II 1 ' ~ J_ J I 77 I .7+n,r.-Yj I r I ~ 111 { ` ~ O m -

-- R S r,d_ ^C MS I I I I ~ ( L =JT ) symycoms & ,lei 5 2 v ° :" ? ! ho l1 r ~ ~ 1111111i1 I` ll J

L .7zr CauS ; YCO to :

d _ ~ I t o ~~?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 r od '~C z _' - (' 0 C 2

_ . . ion ~ critical ._ C u5- ._ c __ G'1 :__ d E : ax 11 to - ~ . - - - - - „ ~ - _ - - - 1- ' - _ ` _' _ _ . _ ~ ' - - - ~ _" c _ _ . _ T - - -- : . 7 i-f - ~ - ' - ~ - - - - - - - - ~ - . 1 0p . 51

GROU? lY ~ SJn j ECT DATE E- c c~ z z COND . 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
I ' 1 

# S?UTUM 

# 1 I l SU3STEqNAL 

### SORENESS 1 ~ OR 

### AWARENESS 

# ( Q


### SORE THROAT 

# ( . .ca_ R

# s

- 

# ::Ess SHORTNESS OF 

### BREAT H 

# ,r A

# s=-= ~ S"C

# us F

# GE,' 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,- d aer cause vou t o -ou

_ : . . De^r__se oc -,_c . . .__ or recreationa l 3 . ' :a_ :e adc_t=ona '_ , . ._-~_ca tio n C . Be una .,__ ~„ cer_j ._ the raa :czu :n a .. .~1 . . ., e_ ~o ,,cu could nor Ma - : .' czr_ :~

__.

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

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

### p . 5~k _"- 42-7l C O
1= :;Oid} C3 0 c - L C--_ 

### I !
0 

# UG 

# =

S 

### o ?' f Qe_^' (Ot- fiO~°SL ;InC~ 

# I i 1 I _

~ -A

# _S~ D CCt1Gs"= 0 

# A~~
.. ._ N 

# c I ~ I 1 ; 1 1 (



# ► ~ ~ , _ 1 I --- ' ==-=-===o~~ ' 7-7 

### 1 I

d~

-~- _C t :er C315~ `r!tl ~J ~ ~ , ` \

to zc! ; ~_= a D~c' oo ac_ ar r° -_ o 7 1 Tz' _~zca a_ __ on~ '= . ._ 7 P u r ._ ., _ _ _, _ . . ? _ _ •~ _ '~ : 1 _ 11 . ' - ., _ . _ ~- ~ _ _ . _ _ " _ ' ~ _ . _ _ _ _ . _ _ _ ~ - _ , _ . V O C - - _ - _ _ ~ ' , - - - - " - " - - - - ` - - - -- - ' - - - - - _ _ _

### p . 5 3



# y S = - _ c C

# :.~ ~ .^ ^ C __ __ ~_ = :_ ,_ •_ 5 

### C 0 a - C L= : :0 i4~ 2(3= C2 - y- - - G: ,n ~ rr , c _ 10-'s=_a ''0-Y C _ J L != ^ 

## c 

# 3 U e

# 77

S 

# ? uTU

# M ~ ~ ~ f( 1 1 f ( ~
s 

### U 3sT 

### E : 

### N s 

### 0 ? 

### N S 

### -Z O R SOR T 

## (or~ E

## o~_

# Rs .r~s~

~ li e



# ~ 110 

# 1 0 lo 

### D C

# u~_ -2

# . C0 

# ~~ c 

# I to ~rc_ -51,- 1-

C 

## sT ,

## ~~Y'r-.~ :,/
1 -t 7 

# I 1 1 ~ ~ ~ ~~



# - ,3 

## ,r

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 ;

.~ , - - • - - - :I = - .

### p . 5

~ c - - _

c c L'J=_ _ ~, 7 L O== :YC 7 ` CCUG=

SOR E 

## (o r 

## o ~A R

## s Z N

## r~ss > S E OR^

# NES 

# 3 0? 

# E • ~ ( 

# v A

# st D 

# scu AR 

# c
- -, 

# / CONG 

### ST O N

Z



# _ N

# ~
-7 Z



## ~ I 

# ____ __ 1 1 I ~ 1 1! = 1

=c^ s~•re-~_ ou -s, ~ ~~ ~,~ I ` ~✓ ~ ~ ~ ~~~ ~~ _c cus e 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 ❑ 

### ~" ? 11R2C_ _ 

### z J De _ _ O_ _. 

### the - Wll' 

### a --~C u_^_ 

### z c- CCU, ~ +=C „e - T c r ._

_

ll^ : J O :' .,, VOu= L ' 5 :1 .-C Z C ~ OC__

.. . 7

### ~ p .5



## _ ( ~ 

## ~ ~ 

## _ !~~

( 

## -` ~ ` `~r ~ , ;~ ~_m ri . ~ -- ~ j( U ~ ~ ~ `~ ~ ~ ~ •

_ C 

### 0 9 D

- S L
. .Q ~__~G C L` Z G : 6: X 1 

### NT 09 2n=J : 

### 0 D 7- -IF n c^ C! ; = C C G J c >- iCS 3 OS r- ti E
. ~ c:: cr . L C= - - '-, - D LO-7_dC_ D . ~ G l - _ .--_ ~ ~ : ~ ~ r .- ~ ~• ~ OUG ~

J

# P LT`~'IJi'~ 0 LS a ;~ A 3 E X E :, "
lor ROA °S ) « ✓

rNESS C5
3 cOR`",lESS OF 

# H_

_ 'A

# Sr T ' '_ONG c,Smrp v

rIG 1 I I I I I ( ' 1 i ~ ~~ST T=GH~^"I-SS / ° ._C" ! 0_v ( ~ l' ~ _

_

0

# . i 

### NO 

# \ 1 i 1 \

_ 7 

# -) ~ ;, ~ a 4 I _r~~toas & 

### di =co~ z se ver a nours 

# C7 d t-e,r cause you to : 

### t o 

### , .- Ff 

### ) Dec-2ase ootionzi or rec-_ntions ~ .ctivitr Gist m . '_ ~- ~ ~ acd : ona? meaicat io n Be unable to pe :- :O :' ... the ^a :cLt m `-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- B e u n-1 0 1° t O D? 1~/° C r C Q , r v : O_"m l .. u :- u s " l .._ a act o
. .'f : O'- ~ O C v C L _ t, :. ~ _ ~ . ~ . . . . . . - ~ ' ~ -- ` - - ~ - - - - :' ~ - - . ' : .. . ^ ' - -- • i ' - ` - - - , - - - -

### p .56

C 

## a S C 0 V E
. 2 0 CD_ a = -C ^C~ 67 r--

_ .' LC=__vC~_~ .
j C- 

# 130 5 5 > > ~ ~ ~ 5 smJ,

# I~

~u S sL : .'

. N s L sC? E- V1s S 

### j E, s S 

# 5 1 ~ ~ ~ ~ j 1
E OSr

.Y

### -Z s 

### s 1 t



# lo C

# -I I o S

. .~/// 5 

## rc - 

## s T7 

## a 1 0 

# z 1 :y

# G 5 1 ~( ~ ~ ~ ~ Csac -0 

## y_r~ ;s/ 

# 1 f l~ G J ,VO ~ 

# ~_- S___ ~~ ~ ~ I 

# , 1 , 1

# ~ ~ { ~ ► ~ ~ ~ ~ i S __~~^ ) 1 , 1 r f J^ f V 1

_ I I - e•r e r -1 ou 7 s e,,- c- use vou t o 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,-_

### JIp. 57Z- , d I R

# oU P 1'2 

# -3 i SUBJECT NO . 

### DATE

_ H '- C COND . ~ c ~, ~ Y ~ z ~ z SCCRING ca M ~ H Q < H H X != :dONF

. 20=

### MODE R~TE 

### Cr . H H = C - ~ V G 5=T°ACE 30=SEVE : E a c ~ ~ r=: ~ ~ ` E ri E, E-• 10= M ILD liO=INCA° . C4 x H x ~= ~ x ca x c

_ ._,, ca m x c~ °, COUGH 26" SPUTUM 

# I / , I 

# / I 5 OR AWARENESS 

# / r I 

# / / I l SORE TEROA T (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 w o--_?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 

### lw Or . , 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='



### 4 ODER_^ 

### C Q c~ o ~ ~ ~ 

### 30=Sc :VE3L m M

_ ~ C . r

_ .~ 

### -7 ~ D 

### 4 0= YC r

_ ., ~ c= : z 

# AU Ga 

# 1 ~ ~ ~ l l i~ T-J ,~,tt3STERNAL 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 X S 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 6-27 SUBJECT NO . DATE J ~O- ~ ~ c ^ ^ F-i L t

# hV-6-
r= a z z COND . o w e .+ 

### SCORING ax H ~ co H ~ < 1=NONE 20=MODERATE ca o 5=TRACE 30=SEVERE 9L. c-a co HcHn w co Hw 10 `- x H x w x x w U' P4 vc c =MILD 4O=iNCaP . a w w cr e; 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 BREAT H 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 

# IT lasted several hour s 

### aould the y cause you to : ( Refer to A -H ) A . Decrease 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

# -T2- 

# ~ C-1 

## CO 

## er D 

## . SCORING ?=?70 

### N *

.' 20 

### =MOD = IIRI " TZ % ' 5 =•- a I_C : j 0 = S c v a ~ ^G• c7 ~n C G cr ; C C ar ~ -~ L : 7- ~ x ^- x ^' x ^- ~ ^ c V LrJ= ._D C~C~- - COUGH 4~b
SPUTU M SV B S1 EaN 1 L SORE-NES S O R -ai ;=3 E :t~SS SORE mc-4ogg, (or SOA$S4YL

.SS JcOR`" N F

.SS 0_ Da_,A `?~ CONGLST T O N
`n 

### --77-
. .uitiGCuvSj_~~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 : Dec-ease OOL10C12 

### l or recreational 2C?i r i ~ Take additioaz_ meiicatio n 1 

### B e unable `~. .7 De=- :Jr 

### a 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= usua L -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 .~- 

### • .E j / ' ' • .. _ ` `, ~ c : c z z CORD . • _' c e= ^, ^, _ = ~ , .: ._ ~= z m c . F c i- X ~ < SCORING 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 .`~

. .~iT

### AL SORENES S OR 

# a:, AR 

# r:z ES

# S Svr .? mE3 O_"-_"_

' ~OZ~1O~DS f'~

..~iILSS ~ f

~~ ~~?~ /y o r I J ~ SEQR`_7Y.SS O F 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 I T
rr ` O :r"L
. :1(
D -•~~ I-~=

.-, :`~~O~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*or m 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= ;orT 

### E 20_C`0_ 

# a `_-_ C

e -- - 

### =- ~-=-C Z 30 5 E ~~ :._ L^='___ C C 0

# U C-

# = 1 ~
S?U`" uy- 

# ~ ~o l s~i ::si~'~is0 ~ 

## o R A .4 

## a3 E 

## :r Z

## s s o SORE ^* -tOR j ~O~ ~'iO~~SGVLSJ / ) m e /0 1 l 

# D lo 

# [ o 1/0



### ~ . ~ I 1 I I ( ✓ 

# ,5 A D S 0

# 4s ~ C- 7

# ~ corrc : .

## s T

## _ay v-=-,7-



## _ 3

## c lh



# D Ii :C`?~C y

77 0 N O

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*or
Tsrn t :~ s uer_cloa d = 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= -1 O 97- 2 0 = : CB= -3, _ '-~ c : C ; c : ^ c c cn !:.z a : c cz - 10=`. :__C ~-C=t :YC ' 

## cocrc= s

# P t;

# TUM

~ . s U3 

## s TEaN 

## t -7- 

## so R 

## = :r -- 

## s s O R $v+ .7'.'
.`~'`<Q A n t~ L ^ ~ (or E OP_•_°tSc

. :rc.SS ) ~U' ) 

### S

# =o R

# m~ 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 7 S3 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 Y

### c 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 : ~JL 

# A- 7

J ~

S i . C a i aFC P 3 C . - ?G G -- - C ; 1= :i0~T 

### E 20=', :oO~~R T .~ CC = c c c - c 

### 5 _-- 

### 1H "-C 

### E :T jOSc;

### v - E ~tl C G-' : ~ 10='-,r ; 

### L D LO=I _CC1° . X ~ X >< ^ I X r= ~ ^ ~ ~ - 

# COUGH
S P UM 1 / ~ ~ I I l 

# 6vSUBSTZaNA-L SORENES S O R SOR E or a 

## O Au 

## sG N 

## iSJ) I ~ 1( ScOR'" N RSS 

### OF DR= : A '_' = ✓ MA-Sr'_i . CONG~ST Off
V =-

# L 7- Zr -7 N G 

# /'O

,

' •~ ~ ~ i ~ _ . _ ._ 7 0 U S

. Cm 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 s t `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 Perform /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~1r , ~~i V ` -~ ~ . ~ - /Vi f ~~`-~ '~ ~~'•'C ~ ~jyt-~ Ji~i 1~ f . ~P r :.1 ~ It G

### WUP I t l 

### St1BJECT P 

# m
. ~ ~ ~ 1 1 ^ ~7 . f ~9Ur~ 

# -7 DA = 

# 12 6~ 

# it Exertion -~-f C?ii C7 Z 

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

### SCOR

# = r=3 

### cn c n P . 

### - `" `Y' 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= !N

CAP . I f f ( 0 . 5 Very, Ver y Little , I ) ` 

### COUIM 1= Very light SFCPAlr1 2= Light S'uBSTE, P ?'I AL SORENESS OR A W AI ;ENE SS 3= Moderate SORE THROAT 4 to '•5 = (or HDA`RS ERNE SS) So rrt -_vhat Heav y S'ti0RTNESS OF BRE AMi S f I~ ~ I ' l I, r 16= Heavy NA -S AL DISM

ARs...~/ 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 '2= NS • _ (LIST) t f , BORG E=ON SCALE (0-10) tt If syumtcros & discomfort ttt lasted several hour s, -- would they cause you to 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) uror'_c) F . Stay at hcme sick ( lose sick time from. 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 c H n o ; U3 C/3 E' at al l 5=TRACE 30=Sr V~'~E -4 C (COD w cr~ 10 ,-= 40=INCAP . 0 . 5 Very, Ver7 Little COU Gi 11= Very light SF= 

### 2= Lig~ht SUBS =

AL SORENES S OR AWAF~~SS 3= I" b derate SORE THROAT 4 to- *5 = (or HOABSS) Heavy SHORMSS OF BREATH
. 16= Heavy NASAL DT

.SC iABGE/ 7 to 9 = CC?NGrrSTION VerHeav y 

### W=ING 10= Ver-
. r, Ve'- ; =T TZQ

HIi q ESS/ Hea vy RESTRICTION 

# F= 

# C--uE IT-

### 9DACHE FRONTAL :NO YES EYE 

### IRRITATION 0 = 

### S = 

### N

S (LIS

# T) 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 fati gue ) 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 ET

### eroe_^_c',7 rcCT?l. ~ ' • /~L~ _Y~` / +/ ~ 11"_ -l .i Jl"~ .' : ` . ... .~ ._ 

### p . ` I ~y$ • I 

### GROUP 

# Z-3,39 SUBJECT M 

### DATE Borg E:ie rtion COND . oi l r--4 

### c N C 

### •, Scale SCORIN

### G ° r~ t5 w w w M xl~i _¢ ip~ 

### cn ; 2 co r--4 

### `V ` n 

### 1='

-.'UrIE 20=-%,!ODERAIE 0=~t~ot1Lng H C-- H z, H 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 

### 1= Very light SPUTCIM 2= LiQnt FUBS TEKITAT St7R=-S i c 

### OR ~IP_IE, S 3= ?~cerate (O ~ ~t, .. .S) L to 15

_ I I Sc~~ v~ .a=



# - ~roR~~-~.: S 

# 0F BR

Z 

# ~~ / ; ~ ; ~=-,:
CO

# . -E-M

# aN ; t

# o -

~ VEO i : ° ...: 'Tv tivr ~ . .7L C- 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 : ==-ON (0-10) l d If syemtoms & discomfort I ~II I 

### lasted several hours , would they cause you t o 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` ~f ✓ y, 4 A~ ~~f~~~~ p . 69 SCORE Sr= 

### M UP

- ~ 

# s'JB.TECr 'U .-Lo 

# A3 -'16 DATE Borc, 

### E.Yeoti

### on COND
. 

### Sc:1e C`1 

### SCORING W 

### c:a z cn c„ cn 1 ' d ~+ ~~~+ ~,y~y~ A L~1 ~ , ~ ~ ►- ~-- F ; C14 ~-+ c+~ 1:1z" i 4 =1`NriL 2o'1J

### D L . 

### TE U. U 

### U ' ' U 

### H H c .N Fi E-4 

### w at all 5=TRACE . 30=SFV1 ~' a -1 c- "" '-' o r10=.= 

### 40=iN

### CAp . Cr 

### 0 .5=Jer 7 

### , ~yV rLi

# tt,e COUGH 

# 71= SgLMM 

### Very li~u 

### I/ I I ( I ,~, ~ S'o3S ~*~1•?az SORE -NESS 2= Li 2~,j t OR S TI I -- , 3= ` n de==t-= • , SORE - A-T ~ t0 'S = (or 

# ~ ~~• ~ l ~ l I l~,~ ~ t, ~ GL ~L~X~:G t 

### SHORTNESS OF BRi.~''~ ~~1+ F~_v ; Si`~1 ! I~- i I I ~' ~ I 

### NASA

J J 

# T D

# , 16= 

### CJ~1=- S 

### ON 

# t o Ve= ; =° . ; 

### v -•:



# _ T ~ S 

### ~ / 

# , _0- Ve,-, , `!e_-

# - (ZEST P\F ,c'gZ~ . = N 

# r =

# cE

# -~_ _ I 

# + :73C-N'



# _ A



# _ . I

S 

# 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 maxi irnsn 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 , cri tical 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~ . . OL

7 

### DA= 5 Z Ct Borg fill E.Yertion COND . Hit I r-4 N Cl) 

### 7 Scale SCORIN G w c ~- ~ cn n cn 

### 1= ' --IUNE 20=

'-,,DDERATE H'-' ~ N ~ M c-xt t t~ E '' 0=v : ~ E-~ ~ ~ othing

~ ~ Ell ci , ~ c n ~ -



### ~ at all 5=TRACE 30=5r V~-cF, w W, ° ° cn 10=-1!T-1,D 

## 40=?

N 

## CAP . 0 .5=Very,Very Little COU M 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 a R., . . 

# ^ f 1 / J t , ' ~ ~ ~ s C

# - .Nbz

# t t ea 

# ,-v H SrOR IMJ 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<_ .JT T!C=!ir :S/ I ' I' ~e='vV 

# RESTF, I

# cr=oN



# C 7 :z7 

# ) ~ t+ t I i BORG E= :10N C 

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

## U I ~ '•~~ t t I I I I L 

### symptoms & discoIILLOr t 

### 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. xz i.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 PTO M SCORE SHEET p . 7r 

## I GROUP v SUBJECT M . ~~~-- DATE Borg Exertion COND . I r+ C14 ~ ~ Scale SCORING Cl ) 

### Wcwn ~ i ~ 1=NONE 20=~DERATE p ; ~ ~ r' Cl) thing H c~n at all 5=TRACE 30=SEVERE °a r ' 

# C' r 10= i= 40=INCAP . 0 . 5=Very , Very Little COUGH Very 1 SPUTCIM light 2= Light SUBSTERITAL SoRII~SS OR AWARENESS 3= Mnderate ~ l (or`'H~S ) 4 to 5 = 

# Somewh 

# at SHORTNESS OF BREATH Heavy ' NASAL DIS 6 _ ~.CHARGE

/ CONGESTION 

# 7 7 to 9 = Very Heavy 1+1H=ING

. CHEST TIGHTNESS/ 10= Very , ry, VeY

_ -, RESTRICTION Heavy FATIGUE 

### HEADACHE l r " / FRONTAL :NO YE S EYE IRRITATION OTHER SYMP'IONS (LIST) BORG p ( ( ~ ~ EXERTION SCALE (0-10) 1 0 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' 7 I 2 GPI DL1~

_ Si1B.7Et,'T Iu . Borb DATE Exe rtion CON ID . C14 r n Scale SCORING w c t 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 Littl e COUM 

# 11LLILL±iLLL1=verylight SPUTLM 10-d 

# ~ 2- L i,-4-i

# t SuBS =M 

# aL SOP= S OR . A1vA_SS 3= Nbderate SORE M-MA S 4 to ;5 = (o2' ~~ OARSE117-15 S) SOt 'i~'aZ7at S'r K R' s~' E.SS OF BRF A-M I I 1 5= -Heavy 7 to 9 CONGESTION Very He- -,,y 

### [vh~ : ZIr1G 10= Ver

### y, Ve_r ~- 

# -=

# T TICH=

# S/

~ ~ PZ 

# S =C'7-ON 

# f ~

_ if , 

# ~~~ CTUE 

# _~ -12ACHE FRD

# tv~'1
. : 'NO YE S



# ~ Z 

# a=,-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 fati g ue) Be unable to perform your usual work activity or level of productivity (~ occunation, scho olwork, critical household duties ) Stay at home sick (lose sick time from work) > Visit your physicia n i . Vis i t an er~ ~e:~cy rocm 

# ' rL5~~!~ii Jl~l i CL r 1 7 p ./7 

### GROU P


# ~ Borg 

# ~°tion 

### COI~ID . Scale SCORING H N H c* ] 

### 1=VONE 20-yJJDF~TE c: It ~ 3 O=vo thing E-4 F-4 

### 5=T RACE 30=SEVE`'-,F w at all x w a a . a cr~ 10= =Z 40=1NCAP . 0 . S=Ve-y, Very Little MU M 

### SFUTZPT 1= Ve~y li ght 2= LiQnt SJBS"~.I?AL SORE"~

. OR AI~iA S 3= I~derate SORE :OA

S (or HDA.RS am 

### SS) , / / 

### 4 to 5 = SCt~*vi]ct 

### S'r_ORTi~iESS OF BREAM 

### i Fe= '



## i 1 

## 6= 'H

## eavy IMS 

### a .L DIS aW

### GE/ CONGESTION 

### „f, I 1 ( I I i/ I/~' l 7 to He---v-,7 

### Ve_ y CHEST 

### TI_SS 10= Ver-~', Ve y RESTRICTION / Flea-,,y F
. a?'I Cl1-E 

### FRON'T?l, :NO YES 

# .,,

-=ON
(LIST) 

### BORG E

XE 7-17 

### 'I0N SC A

### LE ( 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 additiona l medication C . Be unable to preform the ma uxi na m. amount of work that you could normally perform D . Turn this workload level dawn a iSreg ard 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 . T 4

~ 

### ~, (7 j ~JECT NO . DATE { H H C OND . I ( Z H H / F ~ Z ,,~ w O 3 H H E ~ w
► .3 E a x z w w H ,, , .. 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 cc w v~ o w co 10=MILD h0=I14CAP . 3 W a w w x w a o w a x w

w cc ~ a a 

### COUGH' 

# I- 15T 

# (7( SPUTUM 

# . ~ .~S • ~ ~ SUBSTERNAL SORENES S OR AWARENESS 

# t ( r ~ ( SORE THROAT (or HOARSENESS)
SHORTNESS

- OF BREATH NASAL DISCHARGE/ CONGESTION
WHEEZING CHEST TIGHTNESS/ 

# 4A/ RESTRICTION i : FATIGUE

~ HEADACH E FRONTAL : NO . YES
EYE IRRITATION OTHER SYMPTOM S (LIST) \ \ 1 Lf symptoms & dzscvmPq


### . r:t 

# A lasted several hours ., 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 roomp .,75

• GROUP Y,' SUBJECT N0 ,~ 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 H w o w w w H H a a ~ a a 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 COUG H SPUTUM 

### ~ ~ JJ SUBSTERNAL SORENES S OR AWARENESS y ~ SORE THROA T (or HOARSENESS) S ~ ~j ~ ) I
SHORTNESS OF BREAT H 

### NASAL DISCHARGE / CONGESTION 1 

### WHEEZING / 

# o CHEST TIGHTNESS / RESTRICTION FATIGUE /c, HEADACH E 

### FRONTAL : NO \ /

, YE S
EYE IRRITATION OTHER SYMPTOMS I l ( ( c}-r i . ', ~~ 1 (LIST ) 

### If symptoms & dzscomPqrt 

# A-igl ~ lasted several hours, v would they c aus e yau 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 work) G . Visit your physicia n H . Visit an emergency roomGL

:OtTP l -SUBJECT NO . 

### o w c~ ~ DATE r H

!iJ -~~- H H z z

a H H H H W a COND . w 0 3 H a ~ ~ H w o w w w H H 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 S SORE THROA

T (Or- HOARSENESS ) SHORTNESS

OF BREAT H 

### NASAL DISCHARGE/ CONGESTION
WHEEZING 

# -5 

# " CHEST TIGHTNESS/ 

### ~-- t ~ ; I -~ • / ~ ~~ ~~ ~ ,~ RESTRICTION 1 `l
FATIGU E HEADACHE ~l FRONTAL :- NO L--" YE S


### 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 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

### GFiOUP W . Z •✓~ SUBJECT N0 . DATE H H c~ ` H H z W L L' 0 ND . a 3 H H H H 1- 4 " H W O W W W H f-~ a 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 THROA T ( or HOARSENESS) f ~ ( l ( ! ~ / ~ ~ r , ~' ( I 

### SHORTNESS OF BREATH NASAL DISCHARGE / CONGESTION 

# C /v
WHEEZING CHEST TIGHTNESS / 

### RESTRICTION 

# JD

FATIGU E HEADACHE FRONTAL : N0 . YES
EYE IRRITATION OTHER SYMPTOMS ( LIST ) Lf symptoms - & dis•comfq .r :t ~C lasted several hours, , would the y 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 ph y sicia n H . Visit an emergency roomGROUP 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 ► -~ a Q < vc x z a~ x SCORING A4 H H H H w x, ~ C 1=NONE 20=MODERATE ~ E' ~ 0 0 0 S *T,.RACE 30=SEVERE ~ ~ w 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 . w COUG H 

### 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 HEADACH E FRONTAL : NO YES
EYE IRRITATION 

# ( \ 1

- ~ OTHER SYMPTOMS ( LIST) 1- f symptoms- , & dis-comfQ .r,t lasted seve ral hours,, ~ would the y cause - you to : / r (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)v G . Visit your physicia n H . Visit an emergency roomGF:OUP

SUBJECT N O 

### DATE l ~ ~( 1 1S ~ o w ~ t EA F"'~ C7 C7 z L H H 

### z z w - a H H H H W a 

### COND . . 0 3 H a a 1 H w o w w w H F-1 a a~ z fA V] H CA H }C a x SCORING a , a H . H H H H H W x• U 1=NONE 20=MODERATE cc E' ° U o E o x x E F E- + z 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 THROA T (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


### FRONTAL :

E



# - NO 

### ZYES

_ EYE IRRITATIO N OTHER SYMPTOMS ~ Li (LIST ) 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 roomp

G30,UP . 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' ~ r i 5*T~ACE 

### 30=SEVERE w~ G w M w co E 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 COUG H


### 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 hour s would they cause-y ou 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 C ) t S . o x x F E• H z F 5=TRACE 30=SEVERE w 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 THROA T ( or HOARSENESS ) SHORTNESS OF BREATH 

# 10 /10 ~ / NASAL DISCHARGE / CONGESTION Z-) WHEEZING CHEST TIGHTNESS/ RESTRICTION
FATIGU E HEADACHE FRONTAL : NO ►►► /// YES (~ ! ~ J ✓ ~ ~~ I
EYE IRRITATION / 0 OTHER SYMPTOM S (LIST) Lf symptoms- & dzscomPQ .r.t lasted several hours-, 

## ► would they cause you to : CI 

# p . ~ (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 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 

### C H H U n z F H H Z Z w L ' COND . a H H H H w a 0 3 H a H w o w w w H 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=T71 ACE 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 COUG H
SPUTUM ' / ~ `j ~ C~ ./ . . • ~ SUBSTERNAL SORENES S OR AWARENESS SORE THROAT (or HOARSENESS) /3 SHORTNES$ OF BREATH NASAL DISCHARGE/ CONGESTIO
N 7 H~EZ I 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
- you to : l ( ( (Refer to - -- ~ A . Decrease optional or recreational activity Lis t 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 id duties ) F . Stay at home sick(lose sick time from work)y G . V isit your physicia n H . Visit an emergency roomGRGUP

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 a H w o w w w H H ~ .] a a SCORING z `o '••'' X a x LL ~ H H H H H H w x : V U 1=NONE 20=MODERATE W E•' Se o x a E 4 E-4 E-4 z E+ 5= T RACE 30=SEVERE cs : o w cn w ca w ca o w cn M 10=MI L D 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_ COUG H 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 ✓ FATIGU E HEADACHE FRONTAL : NO YES ~ EYE IRRITATIO N OTHER SYMPTOM S (LIST) l % I \ 1 

## r. ;L ?f symptoms
-- & dzs•comfo•r .t C' 2 lasted several hours, would the y 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 nerfor m 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 ) )v F . Stay at home sick(lose sick time from wor k G . Visit your physicia n H . Visit an emergency room

### ~ ,i

GROU . ? 1 ~~ 

## i j ~ ~ J J SUBJECT NO . w o DATE 4 o r

• H COND . H

~ ~ ~i H H H W a a O H w o w w w H H 

### a a a co SCORING z v~ a a a H cn H se a x x L~+ ~ H H H H H H W x• U U i 1=NONE 20=MODERATE w F' ~ U c~ c, c 5=TRACE 30=SEVERE w no . 0 w cH w c~n o ~ a W X '' x w x w x w a a o o a 10=MILD 40=INCAP . w a w x w x a w a ~ a a a ~ COUG H
SPUTUM SUBSTERNAL SORENES S OR AWARENESS 1 L5 ~ f7 S ~ ~//~ l0 ~1r7 SORE THROA T ( o'r HOARSENESS) 

# ' a 1

# d 4

# . A9 / 0 SHORTNESS OF BREATH )0 / &7, ~O b 

## 0 j 

### ~ NASAL DI

t CHARGE / CONGESTION / - '/ 0 2-:FC-E# Z

a~ 

# 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 S (LIST) l 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 perfor m 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 roomp . 8

GROUP hj) '"Z



# 1 ~ J ~I ,~- SUBJECT NO . DATE

~~ I~- ~f1J H w . H c~ ~ z z ~ H H z z w G~ COND . x H H H H w a a Hw 0 a

w w w H H a a ¢ SCORING a`x z v~ m H cn E-+ x ¢ x x Q~ H H H H H H W . . 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 ~ °, P. v a a COUG H
SPUTUM SUBSTERNAL SORENESS ~ / ~ OR AWARENESS t\ l SORE THROAT 

# 10 /
(or HOARSENESS )
S 0 ATNE SS OF I

~ 

### g REATH O 

### L 7 7- 0 c, w-~ lll " NASAL DISCHARGE/ CONGESTIO N EEZIN 1 

# 2 

# - W) 

### L CHEST TIGHTNESS/ RESTRICTION- 

# 76 Z

# o 2 

# 0 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 the y 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 physicia n H . Visit an emergency roomp . 86

GROUP (

# ~ (1

------ SUBJECT NO . !1 i1 y

- / . , w w DATE - E-4 H c~ v z z

~ H H z Z w F 7 COND . . J ac H H H H w ,~ a . o a H a a a H w o ' w w W H H a ¢ a SCORING x a z u~ cn H rr~ H x ¢ -- x

_ 13 . ~ H H H H H H W 0 U 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=MI LD 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 

# /0 .Y>"~ l 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 the y 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 w ork* 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 roomGROUP p $



# ~, ~- ; ~~ SUBJECT 

### NO . !~ /\4 7~ ' w w DATE E+ ► -+ c~ • c~ z z' H H z z w r4 

### COND . H H H w a 0 3 e• a 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 crCOUG H
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 ✓✓ , FATIGU E HEADACH E FRONTAL : NO YE S
EYE IRRITATION l I ~ ~ ~ II 1 OTHER SYMPTOMS I ) I ~ I ( ' I (~~ (LIST) l I If symptoms• ' & dis
- comfor,t lasted several hours- , would the y 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 oo z z . H H 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 E 4 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 y 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 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 roomGFtO"JP ~,,t ' . 8 9 

# j SUBJECT NO . • . -- I ( P DATE w H H U, ~ z z 

### COND . 0 3 H H iHr H W a a H w H

o w w w H F .. ~ a , .a a SCORING a~ z H H H H v~ t~ y~ ¢ ~ x 1=NONE 20=MODERATE H U U C 5=T'RACE 30=SEVERE W. 0 E-1 E., E-+ 10=MI 

### tD 

### 4 O=INCAP . w X '' x w w w ~ o o a H 

### a w a w x w a w rx ~ Q, 44 

### Q, 

## C oUGH
SPUTUM ,'-



# ~ 170 

# -/ SUBSTERNAL SORENES S OR AWARENESS V SORE THROA T (or HOARSENESS) / (/ ~ I 1 ~ ~ ~/j J J+n J/, ~ /~ 7

1 v I ( l/ /( I / SHORTNESS OF BREATH lol / ~? 2 ~'~ ~O ) % 0 NASAL DISCHARGE/ I v = CJ 1 I . J CONGESTION 

# /0 'jj{ 1 

### WHEE 6I{N

~G /1~0 101-1

_

# 10 10 11 20 CHEST TIGHTNESS / RESTRICTION (0 I ) 0 ' 0 C~ FATIGUE HEADACHE FRONTAL : NO YES ~ . I 1 l I ~ ~ I ~ ~ I ) I ~ EYE IRRITATION • ~ ~ f I + I j 111 I OTHER SYMPTOMS 

# , ~ ( •~ (LIST ) ?f symptoms & discomfort
i L lasted several hours• , would they cause

- you 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 z H H W4 COND . 0 :3- H H H ~ a a a W 0 W W W H H CO U) M >< SCORING a ~ Z H H H H H H (c a 1=NONE 20= M ODERATE co F' 0 U Cx 0 rz E4 X E-f a E+ z E ., 5=TRACE 30=SEVERE w w C w C r . W CO W co 0 W co W ~ 10=MILD 4 O=INCAP . w x ~' x r4 X W X W P. 0 W a w w r~ w a :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 ~
HEADACH E 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 roomSiTB .TEC 'r NO .

. I ~ ~70 DATE w w

/ 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 w c COUGH
~.- SPUTUM SUBSTERNAL SORENESS OR AWARENESS ~, - SORE THROAT ~ 

### (or HOARSENESS )
SHORTNESS OF BREATH 

### i NASAL DISCHARGE / CONGESTION r 1 WHEEZIN G 

### CHEST TIGHTNESS / RESTRICTION ,,-~ I ) ~_ FATIGU E
HEADACHE i 1 r ~ FRONTAL : NO . .~ YES l I ~ J f ~ ~ r r EYE IRRITATIO N OTHER SYMPTOM S 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'+ 

### w ,a a o w E '



### w w H H ~ x z ca CO 

### H cn H X SCORING 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= MILD 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) I ~ SHORTNESS OF BREATH ~G ~~ /~ S S S NASAL DISCHARGE / CONGESTION /r ~ /v ~ D 

# J c
WHEEZING 

### 1 

# -30 

# z O 

# ~'o Za 

# 0 /0 / v 

# l s CHEST TIGHTNESS / RESTRICTION 

# 2,0 ~ 

# O FATIGUE 

# 5 EiEADACHE FRONTAL : NO YES _I,/
EYE IRRITATIO N OTHER SYMPTOMS ( LIST) symptoms & discomfor t 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_ U C ~ E- y G ? COND . Z cr y r H, H z z ~ ~z 

### o ,y ►~ G=, a a H r .-7 O f~ ~I L a y r 

### 4 $4 SCORING a a z ca Co 

### M y X ~4 1=NONE 20=MODERATE Q = 0 U U U C c c H E, Ec-- 5=TRACE 30=SEVERE wX H X u u ~ 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 THROA T 

### (or HOARSENESS)
SHORTNESS OF BREATH NASAL DISCHARGE / CONGESTION 2 WHEEZING r U , z ~ Z 0 ic l) 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 (LIST) ~ I symptoms - & discomfor .t 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 c ~ . H o z z 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 ~ 0 U U C 

### 5=TRACE 30=SEVERE w a ~ w ~ CC 0z co o 10=MILD 40=INCAP . ~'' x '-' x w X w ~ w a c o 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 YE S
EYE IRRITATIO N OTHER SYMPTOMS r ( ( ( ~ / / / (LIST) 1 IJ \ symptoms & discomfort sted several hours , sld they cause you to : G ~L efer to A-g ) Decrease optional or recreational activity List . Take additional medic a tio 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
. tA I DATE J ~ 

### ~ c ~ c< J ~ ti z z z COND . r4 o ~4Et-i W O W W W H '"" `-' SCORING a a z 

### co a '""' v

### i < 1=NONE 

### 20=MODERATE C 5=TRACE 30=SEVERE r4 a, a r , cc r4 F' x E' z r

### 10=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 roomf i~ .9 S .UBJEC T NO WA . . 

### DATE 

# P4 . G : 

### z z z COND . 0 H O L+ G7 W H H F~j ¢ C SCORING a a z co m ► -+ cn H y~ . 1=NONE 20=MODERATE c o aE_' 0 ~ H ci H c' v " c E- 5=TRACE 30=SEVERE r--x-~ c 0 C . cEn c-

. m c-a= M oz E' ~' 10=MILD 40=INCAP
. r4 x '-' x r4 X W . x o c 3 f-7 z L 7 t~ G .7 ~ f-7 c~ p . 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 - YE S
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 

## rE

## cT 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 '-' (n " " 3~7 cz W ~ 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 C 

# 2 NASAL DISCHARGE / 

### CONGESTION 

# -5 0 

# C
WHEEZING Z(' ) CHEST TIGHTNESS/ . RESTRICTION 0 ;to FATIGU E
HEADACHE FRONTAL : NO YES ✓ ~ I b 

# if 5 EYE IRRITATIO N OTHER SYMPTOM S 

### (LIST) I symptoms & discomfox .t "8 4 sted several hours , ild they cause you to : A C C _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 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

### .9 8

• • . r - - -9 I ' • ~ ~~ - . . -- -

. i ' 

### ~ q UBJECT NO . .-10V DATE ` ~ E-H G-, ~ ; c^ v c3 z O H H H H W L+ COND . 

### 0 W W W H r 

### E-1 ., 

### a a SCORING z 

### 02 M 1=NONE 20=MODERATE 0 0 0

► U 0 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 BREAT H 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 SYMPTOM S (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 

### z z z z 

### COND . 0 3 H H H H W ~ a + 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'' 0 0 C 5=TRACE 30=SEVERE wc 0 E-4 W co o E E~ 10=MILD 40=INCAP . W x ~' x W x W x w a . a co o~ 3 w c~ w ac w c~ w a ~ a . 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
FATIGU E 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
. L 0G ~ DATE 

## 11 l9 $~ o E H G i C ; C 

### COND . Z~N-x~ =J PJ a H H H z z c-z, c~~ o 3 ►~ w ,~ ~ : H w o w L=i w F F a ' ; r' H 

### SCORING p. 

### M ca H H x o _ Q 

### 1=NONE 20=MODERATE cO 0 o H P_ ~ U C 5=TRACE 30=SEVERE w c ~ ~ 

### Cn M z E, E

### 10= MILD ~+O=INCAP . C4 X '- H w x w x no . 

### r4 co o~ 3 w ~ W ct 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 BREAT H 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