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### WH EEZE - im ~ j ~'' N-~ !o ~ 0 1^~ I C/O SOB C PHYS E X I rn -< ---_ - `- - m ~r`-I FREQ . OF ASTIL'LA ALLERGY t O o 1O 1m c~ m 7 ATTACKS h'0 /YP. HISTORY I-~ Io ;u ~~~ • o i Ln SELF Ll ___q 

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### .14

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### W=- ZING =) I WHEEZE/RALES ATJSC . RESIDENCE LENGTH ~ t---~ CHEST TIGHTNESS HEART RA TE REST WORK LOCALE FATIGUE

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--

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## '~o~IN, s i I I i I I I I I I~ EYE 

### IRRITATION RES T

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A t . m HISTORY Ln I' i


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### t ~ OF WEEK 

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### . 2 0

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### -t---I--{=- I 7 EXERCISE OCCUPATION I I HEADACHE I~ ► ~-- ~-~ ~ :1 MINUTE VOLUME SMOKING STATUS EYE IRRITATION I RES T OTHER 4 r~ MINUTE VOLU ME PACK YEARS EXERCISE WHEEZ E i z o w rv ~~o .- o I{ I C/0 SOB C PHYS E X n FREQ . OF ASTHMA ALLERGY c o o X c~ ' 7,' IATTACKS NO/YR HISTORY ; z 0 ~ 70 SEL F cn -N-i -0 '-C - 0 -t o o j CD m o

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