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DATE ~ o w v °

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0 3 E.

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l0=MILD 40=IYCAP .

W x -, x w x w x w o a c

a w rc w e w rc x a a

COUGH

~

SPUTUM

SUBSTERNAL SORENES S

OR AWARENES S

SORE THROAT f

(or HOARSENESS

OF BREATH ) SHORTNESS ~ 'i ~ ~ 1 ~ '

NASAL DISCHARGE /

CONGESTIO N

WHEEZING If 1 I f ` J(

f I _01411

CHEST TIGHTNESS/ ~-

RESTRICTIO N

~ A~=~ FATIGUE ► ' ' I

HEADACHE I J ~ ( ` ~ r

FRONTAL : 140 YES I

EYE IRRITATION I ~ il ' ~ ~ I

OTHER SYMPTOMS ~ I I , )

(LIST) ~

If symptoms* & dis-com%qr.t

lasted several hours-, 1~ -

would they cause }rou 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 dovn(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
s-- - -- - - - - -

o ~

~ -. SUBJECT NO .

(~

DATE JI 0} "~\ o ! ~,

E M W v J

w w

COND .

O 3 -+ F, W a 1 s , " H z Z w w

i-+ w

0

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s w x w cc w X w

x w x o a a°, a ~

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I THROAT

( orEHOARSEI7ESS ) I J , I I I I ~/~'

V I

6 SHO IIESS 0 BREATH r I I l , I J ~ /~ ~

CONGESTIO

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N

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h hT

/ ' III ~

RESTRICTION h

FATIGUE I ~ ' I 1 I / I r

HEADACHE 1 ~ I I I I I ) I

FRONTAL : NO YES

-

EYE IRRITATION

OTHER SYMPTOMS

(LIST )

~f symptoms- & dtsromPq- r.t

lasted several hours-, /gj ~ ~~

Would they~ cause you to :

(Refer to A- g

A . Decrease optional or r creational 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, school work, critical househo Id duties )

F . Stay at home sick(.lose sick time from vork)~

G . Visit your physicia n

H . Visit an emergency room

___--_-- -- ---- ---- -- - -- - ,~""
p. 33

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W

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COUGH 1 ~ , i I

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OR AWARENESS 1 I

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(or HOARSENESS )

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/9~

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7

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FATIGUE `

HEADACHE

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~

YES ~•

EYE IRRITATION

~

OTHER SYMPTOMS

(LIST)

Ef symptoms & dts-comfQr.t

lasted several hours- , _ _ - -

would they cause you to :

(Refer to -N 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 vork)

G . Visit your physicia n

H . Visit an emergency room
p. 34

. •• ~,

.,r, .,- .y• u,. r- _'

SUBJECT NO .

c~~L~U ~01/

o Ci w

DAT E

~ E, ~S~ ~ - z z w w

COND .

Ll

a 3 '~ " ~ F .a ¢

~,w o w w w ~ ~ a a

SCORING a M z H ~ m ~.

co

H W ¢ U

1=i~ONE 20=MODERATE " c o s x E U E- U H z E~ E+

5QTRACE 30=SEVERE Of. a w w w m w m o w m

x ~-+ x w x w x w a c~ o o a

10=MILD 4 0=INCAP . w cc w cL w rr w ~ o a a

COUG H

SPUTUM -

SUBSTERNAL SORENES S

OR AWARENESS 1 1

SORE THROAT

(or HOARSENESS )

3 ~ SHORTNESS OF BREAT H

BASAL DISCHARGE/ 1

CONGESTION -1 -

,-,

WHEEZING 0 v

CHEST TIGHTNESS/ 1 ~ ~ 1 ~\ 1 IC

RESTRICTIO N I

FATIGUE

FRONTAL : NO YES

EYE IRRITATION

OTHER SYMPTOMS

(LIST) ~

If symptoms & dts•camS4-rt A, A'-A 5C A- I&IOC AO

lasted several hours, rT'

would they, causer q-ou to :

(Refer to A-f

A

. Decrease optional or recreational activity List

B . Take additional medicatio n

C . Be unable to perYorm . 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 vork)

G . Visit your physicia n

H . Visit an emergency room
. ,~--~-

p~__3

5

• .k ;~?<li.: ';s :~~i;-~,:. •~ ;.,a1,. y,.... ._ ' s , ~s yr, -

. ., i - ~ ~ (~ r ;+r'

~.n-^.~r .v~_~.3~9 ._•IY . . .• yi~ .. .'- r.'~..'ai'

S 9' .'.> k; t

t,

. _ -~-

•

~ `•~. - .i~~~"r ROUP

DATE 5,3

SUBJECT N O

Y f~,

~ ~ H ~ y a w w_

. r•C7 C Z Z

COND .

a

~ w o w w w -. ~, a ¢

SCORING z `n x _¢ -

w V U

1=9ONE 20=MODERATE ~d aE ~ E y E Z c~ E E,

5,~= T.RACE 30=SEVERE w w c~ w m w m m o w co M

10=MILD 40=I :4CAP w x o-, x w x w x w a rn o 0

. 3w ~ w r~ w s w rt ~ a a a.

COUG H

SPUTUM

SUBSTERNAL SORENES S

OR AWARENESS ~, ~ ( I

~

SORE THROAT - I

(or HOARSENESS

OF BREAT ) SHORTNESS H

NASAL DISCHARGE /

CONGESTIO N

-WHEEZING I ~ ~ ~ ` I 1~ I

CHEST TIGHTNESS/ `- I + I

RESTRICTION I ~

FATIGUE

HEADACHE

FRONTAL : NO YES

EYE IRRITATION ~ I

S I OTHER SYMPTOM

(LIST)

Ef symptoms & disromfpr.t ~ - .

vould the

lasted several hours-, _

y cause you to :

L

(Refer to A- $

A . Decrease optional or recreational activity List

B . Take additional medicatio n

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

perform

D . Turn this vorkload level dovn(disregard fatigue )

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

( * occupation, schoolvork, critical househo ld duties )

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

G . Visit your physicia n

H . Visit an emergency room

i',
p. 36

~ - - _ _ -- ~ _ --~

:0'1,

1 ~ -l

ZG

SUBJECT

P ( C

:40 .

;0 DATE

/ _ ~ v U z Z

COND .

ITiJ

O a F

~ ~ z z w w

a

~ w O w w w -+ ~ a a ¢

SCORING a~ H_

co M M

H

~ x ¢ = ~

1 .=-N ONE 20=MODERATE co t! U v v

5=TRACE 30=SEVERE w cr ~ w

`s O .- E~ cL E E-E z E» E"

Co w co w Co o w co

10=MILD 40=IYCAP . !C w x w X w a a - w x rr o C

3 w cc w a c~ Q w ~ ~ a a a

COUGH I l ' I

SPUTUM

SUBSTERNAL SORENESS

OR AWARENES S

SORE THROAT

(or HOARSENESS )

SHORTNESS OF BREATH \ J 1 I ~ ~ ~ ~ v

NASAL DISCHARGE/ I I

CONGESTIOII

WHEEZING

CRES T I 1 I I I 1 ~ ~ ~_

- RESTRICTION

FATIGUE

HEADACHE

FRONTAL : IIO YES

l ( ~, ` I I I I

EYE IRRITATION I ~ ~ ` I 1 I I

OTHER SYMPTOMS I I ~ I ~ I I (

LP symptoms & dis-comfort

lasted several hours- ,

would they cause you to :

(Refer to A-ff )

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, school work, critical househo Id duties )

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

G . Visit your physicia n

H . Visit an emergency

.

rcon
. •

37

; . -.,;°zz=" c~ -" -

- - fi~,~~~~,,;,;~,• h` ~~~

'

. "~~. -: :-.~ _ , : :-, :5 :°;•-

. . , - " ' - • - - \.,~- _ - -'h~-- .,~L,_ _'h'

- • _ _ ~a'1:

~~ "wj. .

.

. F~ •:

_~-mr--

- .r . - -

.

GROL'P

SUBJECT NO .

DATE

.

. - _ ~ H H Z Z W

COND . -7' 0 3 H H H H W ~;

H W O W W W H H .] Q Q

`-~,z • 0 SCORING z cc z m m m .

. U H H H H H H W '•" ~J U

1=-NONE 20=MODERATE

Y O S CC E+ EM N U U U U. X E-4 = F, E~

S~T.RACE 30=SEVERE w w v w m W m w m w

10=MILD 40=IYCAP .

~ s w m w x w rc w c~ ~ a a a

w x . X w x w x W a. s o a

.~tY`_~

I

COUGH I ' I ~ ~ t r

SPUTUM

SUBSTERNAL SORENESS / i

OR AWARENES S

SORE THROAT

(or HOARSENESS) I I I 1 I ' ~ ! I /

6

PCM

ESS 0 REATH I I 1 ~ I ~ ! 1 V J~

NASAL ISCHAAGE /

CONGESTION

WHEEZING _~ ~ ~ ► ~ 1 ~ f ~ ~ 5 ~

CHEST TIGHTNESS /

RESTRICTION

FATIGUE ' ~ I I

HEADACHE

FRONTAL : IIO YES_

EYE IRRITATION

OTHER SYMPTOM S

(LIST) 1 ~

If symptoms & dts-comfq-rt -- ~

lasted several hours. ,

would they causr 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 vork that you could normally

perform

D . Turn this vorkload level dovn(disregard fatigue )

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

(* occupation, schoolvork, critical househo ld duties )

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

G . Visit your physicia n

H . Visit an emergency room
p. 38

~~~- - - -- ,

'GROi'P

SUBJECT NO .

LA)O

DATE j .~~1 \ o W W_

~ U C7 Z Z

COND .

r~ 3 r .7 r

SCORING

. w o w w w ~. -, a ¢ a

z H H m

1=tTONE 20=MODERATE C4 E U

5=TIRACE 30=SEVERE w~ n w E"

x P-4 x w w M w m o w ca 10=MILD 40=I x CAP . x w x w a

a w x w x w ac w a o, a

x a

/ I

COUGH ~ ) I I ► ~ ~ ~ ~

S PUTUM

SUBSTERNAL SORENESS

OR AWARENESS I I I I I .

SORE THROA T

(or- HOARSENESS )

SHORTBES~ OF REATH \ I 1 0

NASAL DISCHARGE/

CONGESTION

WHEEZING ~ ~ ~ I I I ID 10 )~ D ~

CHEST TIGHTNESS

RESTRICTION 1 1

/

~ I

FATIGUE ~ I I I 1 I 1 ~ ~ I ! /

I

HEADACHE ~ I I f I ( I

il -

FRONTAL : 40 YES

EYE IRRITATIO N

II OTHER SYMPTOMS I I I ~

(LIST) ( f ` 1 I I

LP symptoms- & dzs-c omfqr.t 0~

lasted several hours, ~

would they cause you to :

(Refer to A- H

A . Decrease optional or recreational activity List

B . Take additional medicatio n

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

perform

D . Turn this vorkload level dovn(disr_egard 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 vork) _

G . Visit your physician

H . Visit an emergency room
p. 39

- - -------- -- - ~ -~

GROUP u I \

SUBJECT N 0

DATE o w ~ c7

~ H z z w

H U v z z

W

COND . 3 o s h a a -~

a H H H H w a

H W O W W W H H a ¢ ¢

SCORING

a~ z m cn H m H x ¢ x x

CL ~ H H H H H H W X. ~J CJ

1=-NONE 20=MODERATE Y co E- 0 F a F a F z " F E

5=,RACE 30=SEVERE w u o w co :Q cc w cn o w co Cr

10=MILD 4O=INCAP . x H x w x w x w a a o c

3_ w cc w cc w cc w cc ~ a w

COUGH

SPUTU I

M SUBSTERNAL SORENES

S S OR AWARENES

SORE THROAT

(or HOARSENESS)

I ' ~ 1

SHORTNESS OF BREATH

NASAL DISCHARGE/

CONGESTION

WHEEZING

CHEST TIGHTNESS/ \ l

RESTRICTIO N

FATIGUE

HEADACHE I 1 I I %

FRONTAL : NO\X~ YES }I

i •~~ ~ 1 ~ ~ ( ~

EYE IRRITATIO N

OTHER SYMPTOMS

EE

(LIST )

If symptoms & discomfQr

- , .lasted several hours

vould they cause you t o

(Refer to A- H

A . Decrease optional or recreational activity List

B . Take additional medicatio n

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

perform

D . Turn this workload level doWn(disregard fatigue )

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

(* occupation, schoolwork, critical househo ld duties )

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

G . Visit your physicia n

H . Visit an emergency room
p. 40

--

/OUP

DATE

~ ~, -• z w

E- ~+ o o z

cc `, ~. ~ N w a _

COND . zo s E

~+ w co w w w ~, . a ¢ <

SCORING x ¢ ~ -

1=tT0NE 20=MODERATE o E ~ E m F s

w m o w m

F

5=TRACE 30=SEVERE w a: d w m w co

10=MILD ~+0=IYCAP . W

s w rs w c~ w cc w cz

x x w x w x w r~ o

~ a a

COUGH / ~ J f ! (

SPUTUM I i ~ l I,

SUBSTERNAL SORENES S

OR AWARENESS I I (

SORE THROAT

(or HOARSENESS) 1 I J 1 ! { ~

SHORTNESS OF BREATH I' ) I I ~ ~ ~

NASAL DISCHARGE/

~,;,,. . ..

CONGESTIO

G N WHEEZIN

CHEST TIGHTNESS/

v ~- RESTRICTION I 1 j ~ 1 ►

..~., ~ I I f I

FATIGUE

U~ .

FRONTAL : E IIO_ YES_ r

EYE IRRITATIO N

OTHER SYMPTOMS

(LIST)

Ef symptoms & dis-comfqr.t

lasted several hourg,

would the-T 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 mazimum 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 vork)V

G . Visit your physicia n

H . Visit an emergency room
p.41

_ - - , -5 r

fy ~ - - - - - " --- -- ~ V I ~ " - ------ - ` - --~~ - -- -__ - -

3ROU~'

SUBJECT NO .

DATE o 3~LU ~US/ ~ ~ w w

E H U U Z

)S~ ~ w c~ v

=

L,/J-/ H H 2 2

w

COND . o a N a a -

a H H H H w a

- H w o w w w H H a ¢ a

CL z W co M x

SCORING =) H H H H H H w U U

1=NONE 20=MODERATE `n E' ° 0

Se O s cC E ~ E+ c~v E-4 z E.

S~TaACE 30=SEVERE w is: o w m w w m 0 w m

10=MILD 4 0=INCAP .

W x x w x w x w a rc o a

w ~ w z w a w a M a a

: COUGH

. `-~. SPUTUM

SUBSTERNAL SORENES S

OR AWARENES

THROAT S SORE ~ ` ~ s~- /1

r ) (o 1 HOARSENESS

SHORTNESS OF BREATH

NASAL DISCHARGE/

CONGESTION

WHEEZING 1 T- lo

CHEST TIGHTNESS

/ RESTRICTIO

E N FATIGU

FRONTAL : 80_ YES

EYE IRRITATIO N

OTHER SYMPTOMS

(LIST)

~f symptoms- & dtsaamfCP-rt ~~- A 5C. A- '~~5,L

lasted several hours- ,

vould they causr y'ou 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 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 vork)

G . Visit your physicia n

H . Visit an emergency room
p. 42

~ ~~ - -

OUP

SUBJECT (q0

DATE ~/-

COND .

F 1 ~

SCORING

1 '70'

0 ~ 30~g ~DERATE

-MILD 40NGCApE

w a W >1 n E~ U ~ 07 ~

CQUQH S W C x 0:1

W ~ k W C W

W ~ yWC ~ 2

SpUTUM =

O

SU ~ r / f ~

F?SAZ

OR BAwA ENSS OREHESS

SORE THROA T

(

or

HOARSEBESS)

~

I

5~0

NE

SS 0

BREATH

COGEST CHARGE/

10

N

~

WgVEZIRG

CgEST / ~ ~ / /

RESTRI TIORHESS/

FATIGUE

gEADACgE l I I

FRONTAL / ~ / L ! :

NO

YES_

~ l !

EYE

~E IRRrTATIO~f

( LIST) MP TOMS ~ I I ~ I ~ I

voui d Paev~r 1~#s-epmSQ r.t

( Repert ~oq cauy ~

A

o~u'to

:

Decrease

C

. Take additptiOaal or qb

D . Perra~le to perfadicatiornatiOnal activ.i t

tb, ~

the Turn maZ Y List

E

Be una torkl°ad level amount or uO r

G .

StaY c8~ Pation Pesh rm YOUr du u

G . a k that YOU cOUl d

$ .

713 It

Youome sick~iolKor k . c W°r~" ac~ati8ue) normallY

Visit an emehgcIIC~a~ o~ sick timectrom

o~org iid duties)1 Of Product

iPitY

`-`"
'.=~•~~;,-

„

_ = = C'R OUP ~

SUBJECT Y0

DATE w

.

. • . ~ . N N z z

r N U U z -

•

COND . a

H w o w w w H N a ¢

a

o s r a a

SCORING ~ a z co an M H x a

= N H M H H W ,.~ U C

1=-NONE 20=MODERATE mY O E

U C.) ~

- CC E-.

5,~= T.RACE 30=SEVERE w u» o w c w m w cn o w ~ =

10=MILD 4 0=IBCAP . W x H ae w x x w a cc a

s w cc w a w x w ac ~ a

COUGH

I ~ J ( +

l I 1 ~ ~ SPUTUM

SUBSTERNAL SORENES S

OR AWARENES S

SORE THROAT I \ ~ J ~ i I

(or HOARSENESS) ~, )

f~~BESS 0 REATH I I ( ' 1 I j r~ I

NASAL ISCHAHGE/ ~ I I 1 ~ l 1 J + ~

CONGESTION 1 I j 1 / f

WHEEZIN G

CHEST TIGHTNESS/ ~ + I I ~ ) I f J

I RESTRICTIO N

FATIGUE

HEADACHE I l ` I I ~ ~ 1 (

FRONTAL : 80 YES_

EYE IRRITATION

OTHER SYMPTOMS I I I / j ~ ~ ~

(LIST )

IS symptoms & dis-comf(p r.t

lasted several hours•,

would they cause- rou 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 normally

perform

D . Turn this workload level doun(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)

G . Visit your physicia n

H . Visit an emergency roo m

' _.

. ----_-- - _-_- -- ---- -- -- -- - -
p.4~`sy w`~?.'_ '+~c

.o'-5~,4^Iw,

._ ..

. --Y•~S"~=,

.Y" "E"'-a

:. .~ ._ `~~'s'~~

='~'•`i :~'•"<`7. .~ -_- • ._ ~_$:_ ..' ;?',~~jF, . - ~ •~- ~,:'7~'

~"~Q •~- t.._

:

♦~S..~r;rs•

-J~' +r~ •~

.Y~ `

L•

~ Jl

•'~: ~~'"`~~ g0UP

"

SUBJECT N0 .

DATE

~ ~ U Z

/ H H Z

E -

H v U

Z

C014D . !-7

`

m , •• ~ a w a

o a ~ a a

. w o w w w ~ t- a ¢

SCORING

x

r,r P . m .- . I-A r-. ~-. w _ o

~ 1=tTONE 20=MODERATE ~ co E-4

~

E, s F a F z E5-T2 ACE 30=SEVERE w a w m w w co o w

10=MILD 4 0=IIICAP . W x x ~Q x w x w a X o

-s w x w y w a w cz m a o..

COUGH

~

SPUTUM

SUBSTERNAL SORENESS

OR AWARENES S

SORE THROAT

(or HOARSENESS)

SHORTNESS OF BREATH ~ j j I , 1

NASAL DISCHARGE/ ~ I ~ I I

I CONGESTIO

G N WHEEZIN

CHEST TIGHTNESS/

RESTRICTION ( 4 I +

FATIGUE 1, i I I ~ I I ~

HEADACHE ' I I I ~ I

FRONTAL : 80 YES

EYE IRRITATION ! ' , ~ ~

OTHER SYMPTOMS / r I I. ~ I I I ,)

(LIST )

If symptoms- & discomfq_r.t

lasted several

would they causehours-, _ 7you 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 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 vork)

G . Visit your physicia n

H . Visit an emergency room
p. 45

SUBJECT N0

. LA)O

DATE t~~S 9 C o

E

CORD . 0

H W O W 7

3 H ~H ; ~ a a

¢

SCORING z m H m ,H x

1=-NONE 20=MODERATE E a= H H H H H H W =, U

"

5-TRACE 30=SEVER : w co n w ~ w ~ w E~ o E10=MILD 40=IRCAP . 3 w X W ~ w a

COUGH ~~ O I I 1 i J~ ~

SPUTUM t l ! + ~ I 1 f ~ I

SUBSTERNAL SORENESS 1 I ~ 1 I

OR AWARENESS I I I

SORE THROAT

(or HOARSENESS) ~/ I I f I I ,

SHORT&ES8 OF REATH \ ( IV I

NASAL DISCHARGE/ ` I i ~ ~ I

CONGESTION /I

WHEEZING 10 1 0

CHEST TIGHTNESS /

RESTRICTION

FATIGUE / I I I , I I , I

HEADACHE - ~ I ~ I I ~

FRONTAL : NO YES I I I

EYE IRRITATION ~ I I ~ I I ~ I ~

OTHER SYMPTOMS I I I

(LIST) , ~ ~ I I

Lf symptoms" & dis-C omfp-r.t ~Q~ Q~C P~x ~C Axb ~ f~

lasted several hours ,

would they cause you to-

(Refer to A- $

A . Decrease optional or recreational activity List -

B . Take additional medicatio n

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

perform

D . Turn this vorkload level down(disregard fatigue )

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

(" occupation, schoolvork, critical househo id duties )

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

G . Visit your physicia n

H . Visit an emergency room
p. 46

,------

-, ~

~

GROL P

SUBJECT NO .

DATE o w I

r V U Z

CORD . f

0 3 EH a

, ; H z Z w

o w

SCORING x a

1=-ftORE 20=MODERATE m F' ° v ~ ~" `~ w =

5=TRACE 30=SEVERE ~ n°-. U w m w E ~ F' z U C•

10=MILD LO=IftCAP W x ~-. x x v~ w ~n o w CO . 3w x w x w a c~ o

w cr w a m w a

COUGH ~ ( 1 1 ~ 1 I ± I I

SPUTUM I I I ) ( 1 I

1 SUBSTERNAL SORENES S

OR AWARENESS ( I I

SORE THROA T

(or HOARSENESS )

SHORTNESS OF BREATH ~ 1 I ~ ~ I u I

NASAL DISCHARGE/

CONGESTION

WHEEZING

CHEST TIGHTNESS/

RESTRICTION I l I ~ I ~ ~ l

FATIGUE II ~ l

HEADACH E

FRONTAL : RO YES I I ~ f

EYE IRRITATION I 1 ~ ~ I I 1 I ~ I '

OTHER SYMPTOMS I , I ' I I ~ I I

(LIST )

i IP symptoms & dis"comfor.t

lasted several hours-, ft ~

vould they

(Refer to A-f

, cause

f

you to : -

A . Decrease optional or recreational activity List

B . Take additional medicatio n

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

perform

D . Turn this vorkload level dovn(disregard fatigue )

E . Be unable to perform your usual vork• activity or level of productivity (* occupation, schoolvork, critical househo ld duties )

F . Stay at home aick(lose sick time from vork)

G . Visit your physicia n

H . Visit an emergency room
p. 47

[16'1 A Y'11 ("T~'`~~
p~

OUP -

-t'. 1 r._ /

SUBJECT No . ~

DATE

1

COND . 0 3 H , ~ E a a

ra W O W W W i, H a Q

SCORING z

M ~ ~ ~ ~ x ¢ M a= )I

1=N0Nc. 20=MODERATE F' 0 E

5=T~ .RACE 30=SEVERE w a: 0 cn cw co w cn o co

10=MILD ~tO=INCAP . `~ x x w x w w a cz o

3 w ~ w x w cr w cL ~ a a

COUGH

SPUTUM

SUBSTERNAL SORENESS

OR AWARENES S

SORE TH ROAT I ( I

(or HOARSENESS )

SHORTNESS OF BREATH

NASAL DISCHARGE /

CONGESTION

,

WHEEZING

CHEST TIGHTNESS /

RESTRICTION

FATIGUE

HEADACHE ? ( I

FRONTAL : NO YES I I

EYE7L IRRITATION

OTHER

(LIST)

SYMPTOMS

'

I I I

I. f symptoms & discomfort

lasted seve r al hours,

would they cause you to :

(Refer to A-ff

'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 productivit y

(* occupation, schoolwork, critical househo Id duti.es )

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

G . Visit your p h ysicia n

H . Visit an emergency room
p. 49

GF.OUP .

•

SUBJECT Na •__---- > .~n ~ ~" %, c~

DATE EC 0 ND -

H w o w x a z m w '~ H ,~

w

S C o R I 14 G co , ..i >< ¢

1=NONE 20=MODERATE co U C.~ U

5=T.RACE 30=SEVERE w~ ~ w W

w

co w cn zo w 10=1fTLD aO=INCAP, w?` X w x w x w Q ~

3 w c~ w cc w rs w ~ ✓ ;a

COUG

H SPUTU M

SUBSTERNAL SORENES S

OR AWARENESS

SORE THROA T

( or HOARSENESS) 1 ~

SHORTNESS OF BREATH

NASAL DISCfi_~.RGEJ

CONGESTION

~`.

LL Z-)

WHEEZING

CHEST TIGHTNESS /

RESTRICTIO N

FATIGUE

HEADACHE

FRONTAL : NO YES

i

EYE IRRITATION r

OTHER SYMPTOMS

~ 1

?f 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 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)Y

G . Visit your physicia n

H . Visit an emergency room
~„ •

p. 50

~

GROUP_ -- :

S U BJ E CT NO

~I~~~~ . DATE_ o w U

F r c~ ~ z

z

COND .

0 3 E a ~a' a

~-, w o w w w r -+ ,.~ a

SCORING 0., _ • t F, r - ca U

1=NONE 20=MODERATE `n E' ~ o

5=T.4ACL 30=SEVERE a 0 w co w cEn w cEo w o CC

10='kILD 4 O=INCAP . W

x '"' x w x w x w a r~ o

3 w X w cc w cz w a~ a a

~--- ~

COUGH

SPUTUM r ; ~ I

SUBSTERNAL SORENESS I ry ~ r I

OR AWARENES S

SORE THROAT

(or HOARSENESS) I I J

SHORTNESS OF BREATH 1 1 ~ ~J I ~ `

NASAL DISCHARGE/ 5-1 ~

CONGESTIO N

WHEEZING

CHEST TIGHmgFSS /

RESTRICTIO

E N FATIGU

HEADACHE / ~ 1 I

FRONTAL : NO YES ~ r J I r(

EYE IRRITATION I / ~ )• I ` ~

OTHER SYMPTOMS

(LIST)

?f symptoms & discomfort

lasted several hours, ~)

would they cause you to : j

(Refer to A- H

- A . Decrease optional or recreational activity List

B . Take additional medication ,

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

perform

D . Turn this workload level dotrn(disregard fatigue )

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

(* occupation, schoolwork, critical househo ld duties )

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

G . Visit your physicia n

H . Visit an emergency room
p. 51

1F1OUF~~

SUBJECT NO .

U

DATE I ~ ~ Z ~ o w cw~ F ~ c~ c~ z

~ H z z w

COND . '- - r r w ~

H W O W W W t-i H .: a

SCORIN G

1=NONE 20=MODERATE

CO c, ~ az E, z

5=T4ACE 30=SEVERE 0 W cn w cn W co O w m

10= -fILD 4 O=INCAP . W" `-' x w x w x w a X CD

W X W ~ W CC W CL ~ CL 0.

COUG H

SPUTUM

SUBSTERNAL SORENESS

OR AWARENES S

SORE THROAT I / 1 J f j ~ r

(or HOARSENESS) f ( I ( I I l

SHORTNESS OF BREATH

NASAL DISCHARGE/ L3

CONGESTIO N J I

WHEEZIN

G CHEST TIGHTNESS /

RESTRICTION ,/ D

FATIGUE I ( ~ ~ I ~i ~ ~ !

HEADACHE

FRONTAL : NO YES

E''E IRRITATIO N

OTHER SYMPTOMS I , I I'

(LIST )

Lf symptoms & discomPvr.t

lasted several hours- , IL}'~

would they cause you to :

(Refer to A- H

' A . Decrease optional or recreational activity List

B . Take additional medicatio n

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

perform

D . Turn this wor kload 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 w ork)v

G . Vlsi-

- your physicia n

H . Visit an emergency room
p;5

SUBJECT NO

. p k

DATE

E• H c~ ~7 z

COND

. cz H t r w a

O 3 F .~ a

~-+ W O W W W F H 7 ¢

SCORING a a

Z M cn ` ~n ~ x

1=NONE 20=MODERATE Cn U

te o a E- c F F z E,

5=TFtACL 30=SEVERE w c~ v w co w m cn o w cc

10=MILD O=INCAP .

W

3 w rt w ~ w rr W

x x w x w x W a rr o

X a

COUGH I J 5

SPUTUM

SUBSTERNAL SORENES S

OR AWARENESS ~ I ~ f J

SORE THROAT

(or HOARSENESS ) I / ( I I !

SHORTNESS OF BREATH

CONGESTIO

N NASAL DISCHARG E /

WHEEZING

l I

/

CHEST TIGHTNESS /

RESTRICTION r ~ l (

FATIGUE

HEADACHE

FRONTAL : NO YES l!!

EYE IRRITATIO N

OTHER SYMPTOMS f

( LIST )

Lf symptoms & dis- comPo-r.t

lasted several hours,

would they cause you to :

(Refer to A-H )

' A . Decrease optional or recreational activity List

B . Take additional medicatio n

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

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 household duties )

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

G . Visi~ your physicia n

H . Visit an emergency room
Gr.OUP 53

SUBJECT NO .

DATE ~ L~ .~~ o W w

E- H C7 UC7 2

COND . ~

o 3 c ~

H H H w a

. H z z w

H W o W W W H H a ¢

SCORING co co `-' x ,-

(1. H H N H H W

1=NONE 20=MODERATE co C3 U

~rl- o E- X • cz E z E.,

5=T.RACE 30=SEVERE w cs; co w cc w w cc o w

10= qILD 4O=INCAP .

w x w x w x a cr

co

3 w x w c~ rs w a

COUGH

I I ( ~~

.

SPUTUM I, I ~ I

~

SUBSTERNAL SORENES S

- ` 1

OR AWARENESS I I I I

SORE THROAT i 1 I I ~ ~ I /

(or HOARSENESS)

SHORTNESS OF BREATH

NASAL D :SCHARGE/

CONGESTIO

G N WHEEZIN

CHEST TIGHTNESS

/ RESTRICTIO

E N FATIGU

HEADACHE

FRONTAL : NO YES l 1 ( f I (((

EYE IRRITATIO N ~ ~ I I

OTHER SYMPTOMS ( ~ I

(LIST )

T- f symptoms & dzs- comfo-r.t

lasted several hours,,

would they cause you to :

(Refer to A-g -

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

Visit your physicia n

H . Visit an emergency room
Gr.OUP

SrJ1SJECT NO .

17 1

DATE - ~ r ;~

x a w

COND .

+ I H H z z

0 3 F a a

H w o w w w ~ H a ¢

SCORING a

CL ~ H H H H H H W U

~ z m cn H cn H x ¢ ~

1=NONE 20=MODERATE Y O . cr E~ (~ E+ fz E+ z [,

5=T.RACE 30=SEVERE w R; c~ w m cw m w cn w cn

10=~4ILD 40=INCAP . W X `- x w x x w X C

3 W cz w cz W fz W c~ ::D 0.

COUGH

SPUTUM Z~'

SUBSTERNAL SORENES S

OR AWARENES S

SORE THROAT I ~ f ~ I ~ ~ I '

(or HOARSENESS) I

SHORTNESS OF BREATH I U

NASAL DISCHARGE /

CONGESTION

WHEEZIN G

CHEST TIGHTNESS/

R E STRICTION

FATIGUE

HEADACHE I I I I ~ '

FRONTAL : NO YES f

EYE IRRITATIO N

OTHER SYMPTOM S

(LIST) I

symptoms & dis-comPor-.t

lasted several hours. , - ~ - - " -

would theY' cause you to :

(Refer to A- H

A . Decrease optional or recreational activity List

B . Take additional medicatio n

C . Be unable to perform the maximum amount of work that ~ou 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

S . Visit an emergency room
ta

SUBJECT NO . p

.5 5

~

~ OlJ

DATE V ~ o W

E-H ~7 C7W U

z

COND .

~ ~ z 2 W

H W 0 W W W r-+ H `a

a Q i SCORING aQr = h+ F-, ~ z C° ~ F-' cn H x ¢

.--,

1=NONE 20=MODERATE E' w U

o .~ c~ ct E• cz F z

S=T,RACE

H

30=SEVERE w cz ~ w cn w u~ w cn o w

10=MILD +O=INCAP .

W x r x W x w x a a a o

3 w a w ~ w cz w x ~ p a

COUG H

SPUTUM

SORENESS

O R SUBS AWA

RTERNA

LENES S

SORE THROAT

( or HOARSENESS) I I f ~ I (

SHORTNESS OF BREATH

NASAL DISCHARGE /

CONGESTION %

F~

.t 1 ~ (~ / ~ I

WHEEZING

CHEST TIGHTNESS /

I ~ ' I

RESTRICTION

FATIGUE

HEADACHE 1 ' r

FRONTAL : NO ~ YES

,

EYE IRRITATIO N

OTHER SYMPTOMS

(LIST)

I f symptoms & discomfort

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 at home sick(lose sick time from work)v

G . Visit your physicia n

H . Visit an emergency ro =
p. 56

:- .__

DATE w

SUBJECT td0 . OO .

E-

~ H H z z w w 4 H C 7 C7 z z

COND . H H H H z]

o 3 ~ a a a

~

f-i W O W W W H H ,.a Q a

SCORING a~ z ~ H H H H ~ w a U

1=NONE 20=MODERATE ~ E- "

CO E+ fz E-4 C~ E- 4 z E+ a

5=T,RACE 30=SEVERE w c: co w cn w m w cn 0 w m CO

10=MILD 4 O=INCAP .

W x `~ X W x w x w a, ° a

3 w !~ w x W CG w fL ~ P. LL a+ U

couGH /0 S /0 i~ 1 ° ,o /v 2 0 zo

SPUTUM '70 )o Z , ~O 20 20 2D 2v 2~

SUBSTERNAL SORENES S

OR AWARENESS

SORE THROAT

( or HjJARS~F~~ /0 ?-& 2 .0 ZD ,za Zlj ZO

SHORTNESS OF BREATH lv (0 ( D ld (0 /0 /0

NASAL DISCHARGE/ ) D

CONGESTION 2 2 ~ .2-0 ,~? 6 za zo 20 ?D 2e 26 2a D

WHEEZING /~ ~ /Q /D ~LO 2 b Z0

2b~ Zo 2-0 . 2-0

CHEST TIGHTNESS/

RESTRICTION l f ~ ~0 10 /0 (0 to /17 1 0 .

FATIGUE 1 0 10 (0 10 (j

t :7

HEADACHE

FRONTAL : NO YES

Ip ,

EYE IRRITATION 1G' l0 ! O /O o

f a ~c7 1

SYMPTOMS 0 OTHER 20 f t ~ Z ~ ~ I 1 ~ ~ j

(LIST) 5,VkEd1Ak

Lf symptoms & discomfort

lasted several hours,

would they, cause you to :

(Refer to A-H _. .!

A . Decrease optional or recreational activity ListhU~~-( ~rl

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 . Vi.sit your physicia n

H . Visit an emergency room
p. 57

GROU P

SUBJECT NO .

DATE

~ ~ . z z w w

COND O 3

r-~ W O W W r 7 <

cL CG z c1] n --G~ r X Q_ ~ =

S C 0 R T_ :V G

Nl 0~N 20=MODERATE =' E• E~ z = c

5=T,RACE 30=SEVERE w x ~ w u~ ~ m w ~c o w n n ro c

10=MILD 4 O=INCAP . 3,-~ w x w cXa °-~ c

COUGH

-26

SPUTUM ,2-0 ~J J 2D Z~ 2~ 2L 2o

SUBSTERNAL SORENESS ~

OR AWARENESS

SORE THROAT

( or HOARSENESS) lU 10 I 1 > ~ ~ ~ Iv

j

J

to lJ /J

/J

SHORTNESS OF BREATH /J f ~ 1 ~J I> IJ ~~ ~J /v to

NASAL DISCHARGE /

CONGESTION 10 -.ZJ 10 l~ .ZO 1 L0

WHEEZING 13 w .U i 2c~ sc

CHEST TIGHTNESS/ ~

RESTRICTION ~ ~ ~ (b Jd l~~ 1 IJ

FATIGUE /0 1 ~ 1 ~ ' / ( I l I

HEADACH E

FRONTAL : NO YES I

~y I~J

EYE 1 D /v /U 10 V to /J

. . _TRR T~ :m ATION

OTHER SYMPTOMS

2 4

(LIST) gvfz ijti' G

Lf symptoms & discomfort

lasted several hours,,

would they cause you to :

(Refer to A- $

A . Decrease optional or recreational activi,:y r ist G 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 do wn(disregard fatigue )

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

(* occupation, schoolwork, critical househo id duties )

F . Stay at home sick(lose sick time f rom :ro :-k)v

1 . V_sit your physicia n

H . Visit an emergency room
p. 58

GROU P _

~

( ~ r• ~ i ~

SUBJECT N0 ,

DATE

`-4

COND . cr o 3 `' ~, a

E- 4 w w ~ ~ ~ cc c~ r-, ~ yC ¢a

SCORING r

1=NONE 20=MODERATE

S=T,R ACE 30=SEVERE w c: ~ ~ n w E-4 w n o w

10= 4ILD 4 O=IiVCAP . w x r-, x w x a3 x

s w x w x w c = a

COUGH L0 Jo

SPUTUM LO Iv ri d '2 C -2 Zb D

SUBSTERNAL SORENES S

OR AWARENESS

SORE THROA T

(or HOARSE E S ~'~ ~ SJ I ,/d lU ( Q ~v 1 G_ I1 /v

SHORTNESS OF 3REAmH j / ~/ J ~J Z ~ ZU 2 q 2 4 ~ 2p i

NASAL DISCHARGE /

CONGESTION -20 2 0 Z ~ ~j 2o Z a 2D 20

6

WHEEZING 20 ,Q D Za Z

C p 2D )-d

CHEST TIGHTNESS /

RESTRICTION

FATIGUE

HEADACHE

FRONTAL : YO YES

EYE IRRITATION

OTHER SYMPTOMS

( LIST) SNtc XI .V G"

Ef symptoms & discomfort

lasted several hours,,

would they, cause you to :

(Refer to A-ff )

A . Decrease optional or recreational activi-,y List

3 . Take additional medicatio n

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

per form

D . Turn this workload level dovn(disregar3 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 ohysicia n

H . Visit an emergency room
p. 59

GROU R

SUBJECT NO 17

w w

DATE E, ~+ U U z

w

I a

z

COND . 0

H w o w w w H H a a

a

a

SCORING a aOr = N H H H r r W U

z m m - m ~+ x ¢ .- -

U

1=NONE 20=MODERATE E' E-1 E.

5=2''RACE 30=SEVERE w~ c ~ r.-~ w n o w n ~n

10=4ILD 40 =I?4CAP . x

x

a w r~ w x :~ w z c a c- u

COUGH ~ 10 a l) /0 /0

SPUTUM 0

2- 20 Z0 w

SUBSTERNAL SORENESS ~ l I

OR AWARENES S I I ~ ~

SORE THROAT

(or HOARSENESS )

SHORTNESS OF BREATH S

S

NASAL

S- % J

DISCHARGE /

CONGESTION 2- a _ Z~ Zv z~ Zr7 z o zc: 20 2-0 20 -2 o Lo

WHEEZING lv 5 5 f~ 5 ~c7 J49F /a /0 ->> d'

CHEST TIGHTNESS/ t ~ ) 1

RESTRICTION

FATIGUE (

HEADACHE

FRONTAL : NO YE

N S EYE IRRITATIO

OTHER SY MPTOM S

(LIST ) SN£~

:f symptoms & dis-comfort

lasted several hours,

would they cause you to :

(Refer to A- H

A . Decrease optional or recreational activity List

B . Take additional medic Atio n

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

perform

D . Turn this -w orkload leve l dovn(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 f r om work)

G . Vi-3 -4t your j hysicia n

H . Visit an emergency room
p. 60

SUBJECT

DATE o w c~

NO .

1~ • ~" w

~

~ H z z w w

~. H c~ c~ z z

COND . ~ H w a a

` o a ~ a a a

0 w w w -+ - a ¢ a

SCORING

a z cc cc M

1=NONE 20=MODERATE F' E, E a

5='I',RACE 30=SEVERE co :a : 4 cn o w m

10=MILD 4 O=INCAP . W x x w x ~:l x w a z o o a3 W cc w cz w w cc ~ a. a a v

COUGH ~ ~

>- d Lv 2 - L~ -ZO ZO ZD I

SPUTUM ?O Lb 2-0 2,) 2-o 12e 2

0 2

Z

SUBSTERNAL SORENES S

OR AWARENESS r f 1 ~ 1( r ~ ~ i ~

SORE THROA T

( or 1-4 ( D 5- J

c

5

SHORTNESS OF BREATH 1,2 ~ to /0 ID f,J JO

NASAL DISCHARGE /

CONGESTION 2-0 2-0 ?-0 20 z o ZD z

WHEEZING ZD 2--0 J Z`7 2-1~1

C)

CHEST TIGHTNESS /

RESTRICTION l 1

FATIGU E ( ( ( f ~ ~ 1 ~ ' ~ '

HEADACHE l i 1 1\ ( I ~ !

FRONTAL : NO YES

EYE IRRITATIO N

OTHER SYMPTOM S

(LIST)

If symptoms & dis - comfor.t

lasted several hours•,

would they cause you to :

(Refer to A- $

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

'o erform

D . Turn this workload level down(disregard fat ig ue )

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

(* 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
p. 61

G .30ti ?

SUBJECT NO

DATE

~ H H Z 'Z ,

0

E+ H U 7 Z z

W U `~

;i] w

COND

. ~ H H H H s7 a

O 3 -7 ~7 a

W O W W W H H ~ Q a

SCORING

~~ z cn m H cc H x ¢ = -

a= H -+ H H H H w ~

1=NONE 20=MODERATE C

C) Ct. F

5=T,RACE 30=SEVERE w cti ~ W ;.n W :n w m o w m ~~

10=4ILD 4 O=I :TCAP . x x ~ra x w a ~ o o aa w z :4 rz w w x a a. ^~ J

COUGH 2_0 2-0 ?° ZD "D 2-

SPUTUM Z1~ 20 LD >v C' ?~2 Zd Zo Z o zG 2-6 2-cl

SUBSTERNAL SORENES S

OR AWARENESS

SORE THROA T

(or HOARSENESS) /0 J OP (

d l v [O 1a

SHORTNESS OF BREATH / 0 S L o 2,0 Z v Zd 2-0 Zo o Zo 20

NASAL DISCHARGE/ zJ zD ZG 2o 2-0 ~p 20 z0

CONGESTION 2d ~ I Zo

WHEEZING 20 Z0 Z 0 Z 0 Z 0 Lo 2-0 L

0

2-

C HEST TIGHTNESS /

RESTRICTION

FATIGUE ~ 0 l

HEADACHE / ` / ~ I ~ ~ 1 1 ~ ! f

FRONTAL : NO YES

EYE IRRITATION .2 e9 f r ( I ( ( ~ , ( ~ ~

OTHER SYMPTOM S w

(LIST) SNE~yI.~/6

if symptoms & dzs-comfort ~i

lasted several ho urs•,

would they cause you to :

(Refer to A- f

A . Decrease ootional or recreational activity List

B . Take additional medicatio n

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

,jerform

D . Turn this workload level down(disregard fat 4_3ue )

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

(* occupation, schoolwork, critical househo ld duties )

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

'i_sit your physicia n

H . Visit an emergency room
p.62

. ✓ : ✓~ .'~ I ~ 3C

SUBJECT N0 .

DATE ~ /

0

E, ~ n z z

H H z w =a

COND . ' ~"~ a 3 H -• H

H W O W W W H - a ¢

; .a a a

¢

SCORING a

~ z cn m H m H x ¢ : =

Q .~ H H 6-4 H H H :4 _ U U

1 = NONE 20=MODERATE ~G oM F v `-) `' ~ C (Z E+ E+ rz E• z r G

5=T~RACE 30=SEVERE PL; w m cn o w cc

10=MILD 40=INCAP . Wa w x w ~ ~ c w z = a a x `-' x W x w x w ~ ~ ° a u

COUGH

zv zv z o ~~1G ~ o z

SPUTUM LO 2~ 7 .~ ZJ 2v Zc' 2`0

SUBSTERNAL SORENES S

OR AWARENESS

SORE THROAT

(or HOARSENESS) ~ 0 ~ Jd jU

SHORTNESS OF BREATH JJ f )~ S

NASAL DISCHARGE /

CONGESTION Zd

WHEEZING 70 (J lP 10 t 0-C) 2c, o

CHEST TIGETNESS/ f

RESTRICTIO N

FATIGUE I

HEADACHE J I r 1 I

FRONTAL : NO YE

N S EYE IRRITATIO

OTHER SYMPTOM S

(LIST)

ID 16

=f symptoms & dis-comfor t

lasted several hourscause you to , would they^ :

(Refer to A - H

A . Decrease optional or recreational activity List

B . Take additional medicAtio n

C . 3e unable to perform the maximum amount of -work that you could normally

.~erfor m

D . "urn this workload level dovn(disregard :'a~ :3ue )

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

(* occupation, schoolwork, critical household duties )

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

G . Vi-sit your physicia n

H . Visit an emergency room
p. 63

C R :)L P

SUBJECT NO .

DATE ~~ r o w

E• H c~ c~ z z

w U C7w

H H z z w =-~ COND . o a

H H H H w a a

E~ a a a

H W 0 W W W H H ,.7 ¢ ¢

SCORING a~ H H H H H H w ~J ~ co x ¢ _ =

1=NONE 20=MODERATE co SC U r t~ E cCG Ez ~ c4 c

¢

5=DRACE 30=SEVERE w ~s: c~ w :n a m w co o w u~ co

lO=MILD 40=INCAP . W x w x :4 x w x w c W o o p

a w w y w a a a a a v

COUGH 20 A0 /J lv l D

SPUTUM 20 142

SUBSTERNAL SORENES S

OR AWARENESS

SORE THROAT

(or HOARSENESS) ~ ( ~ 1 I ~ ~ ( f ( {

f4

SHORTNESS OF BREATH p ~j ~~ ld ✓~ 5 lo

NASAL DISCHARGE /

CONGESTION ~o /0 o /d

WHEEZING Id /J /0 ~v 10 rv

CHEST TIGHTNESS /

RESTRICTION

FATIGUE f 0

E I HEADACH

FRONTAL : NO YES

EYE IRRITATION

OTHER SYMPTOMS ✓ 2 0

(LIST) ~v

1- f symptoms & dzs-comfort

lasted several hours-, ~

would the y cause you to :

(Refer to A- H

A . Decrease o D tional or recreational activity List

B . Take additional medicatio n

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

oerform

D . Turn this workload level down(d'_sregar d fatigue )

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

(* occupation, schoolwork, critical househo ld duties )

F . Stay at home sick(lose sick t'_me from aork)

G . Visit your physicia n

H . Visit an emergency room
DATE c

E c~ c: z z

COND . 0 a

~-

~ 0 W W W H ¢ ¢

SCORING Cl)

a~ r H r r~ w - c - ~ '- x; c~

1=NONE 20=MODERATE c

x O x c~ Ey rz E E z E E-+ a

5=TRACE 30=SEVERE w a. ~ w cn w cr, w rn o W ~ cn

10=MILD 40=INCaP . W x x w X w x w a x c o a

3 W fz W fz W ~ W f~ G. p, C. rr

COUG H

SPUTUM

SUBSTERNAL SORENESS I I I ~ / ~ ~ ~ ~ J ~

OR AWARENESS l I (

SORE THROAT

(or HOARSENESS)

r

SHORTNESS OF BREAT H

NASAL DISCHARGE/

CONGESTION

WHEEZING 17~

CHEST TIGHTNESS

/ RESTRICTION ~ ~ J tl ~ ~=

FATIGUE ~

I

HEADACHE

FR ONTAL : NO YES

LYE IRRITATION ' ~[ I~~ 1 I ) 1 1 ~

OTHER SYMPTOM S

(LIST)

symptoms & discomfort

s ted several hours ,

uld they cause you to

e fer to A-$

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 )

at home sick(lose sick time from work)

your physicia n

an emergency room
p.65.,

SUBJ E CT P`• j~~S~ ,~ - ~ ~ ~ -^ I ~ ~ G7 C• ` L`-)l

DATE c

X

F _ C =

COND .

H C7 C C E ~ •-

W

;

w W t-, H -.7 ¢ ¢

SCORING

a C

=

,27 Cn M H Cl) H x

1=NONE 20=MODERATE ~ o E~ c~ U ~ v "

5=TRACE 30=SEVERE w c CIZ . 0 ~ w El c

co U-1

10=MILD 40=INCAP . W3~ ra rz w cc " w x ;4 x =a a c o

r~ z ~ w a p- Cr

COUG H

SPUTUM ~

SUBSTERNAL SORENES S

OR AWARENES S

SORE THROAT ~ ( J

(or HOARSENESS )

SHORTNESS OF BREATH

NASAL DISCHARGE/

CONGESTION

WHEEZIN

TIGHTNESS G CHEST /

RESTRICTION

FATIGU E

HEADACHE ~ J ~ ~ ' ~ 1 I I r

F RONTAL : NO YES / 1 L

-' YE IRRITATIO N

OTHER SYMPTOMS

( LIST)

symptoms & discomfor t

:ted several hours,

1d they cause you to :

f er to A-EI )

• 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 1d duties )

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

• Visit your physicia n

• Visit an emergency room
p. 66

DATE- ~ I •7~1~1~ c ^,

COND . z

O

O C= F - ~.

SCORING Q~ M co F, y "- < <

1= :ZONE 20=MODERATE U F U ~ =a = U U U

5=TRACE 30=SEVERE U1c~a C X E X

C

~

Ecn w Cn

10=MILD co liO=INCAP . ~ }`__,, ~ ~

.-

X

.~ x.~ ~ ° C4 P-

^ p. ~, a. . cr

COUG H

SPUTUM

1 V ( v ~ D l J

SUBSTERNAL SORENES S

OR AWARENESS

~

SORE THROAT f

(or HOARSENESS )

SHORT N ESS OF BREATH 1

j

~~-' ~ O a V r) V I(~ I~ /~

NASAL DISCHARGE,/ l

CONGESTION

,

~ C-J~ S S

'WHEEZING ~ ~~ I ~O I V ~ ~ I) l O ~~ f v 1~0

~: HEST TIGHTNESS /

R ESTRICTION

--~

/)D ✓✓ G " lJ

~

,ATIGUE

HEADACHE I I / I I ~ /

7 RONTAL : NO YES ( ~ I

"'E IRRITATIO N

~THER SYMPTOMS I ~ ~

(LIST

) symptoms & discomfor .t

ted several hours ,

d they cause you to :

:er 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

perfor m

Turn this workload level down(disregard fatigue )

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

(* occupation, schoolwork, critical house h o ld duties )

Stay at home sick(lose sick time from work)

Visit your physicia n

Visit an emergency room
---- ----.~ . _

, J3

p. 67 r .

DATE /Z- c ~

Z

COND .

~

SCORING CC Cr Cn <

1=NONE

5=TRACE 30=SEVERE

20=MODERATE

_

CO

~ ~ w ~

~ c

C)

~ ~

co CC

10=MILD L O=INC~?P . ~'' " w x w x a cm] co

c

i w cr w cr w c~ w ~ a n

. ~-. cr_

COUGH L

i

SPUTUM z`

SUBSTERNAL SORENES S

OR AWARENES S

SORE THROAT ~

(or HOARSENESS)

SHORTNESS OF BREAT

/ H NASAL DISCHARGE

CONGESTIO

HEEZIN G N W

CHEST TIGHTNESS/

RESTRICTION ~

FATIGUE ' ~~ l~ ~ ~/ ` • ~ ~ ~ ~

17)

HEADACHE

FRONTAL : NO v YES

/

.:J '

7-YE IRRITATION

OTHER SYMPTOM

(LIST) ~

S

symptoms & discomfor t

-ted several hours,

,1d they cause you to :

°er to A-N )

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

( * occu p ation, school w ork, critical househo 1d duties )

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

Visit your physicia n

Visit an emergency room
p.68

U E C ~ `1 0

DATE

COND .

C G E- ~ ~ ~

u G'-' h-i F" ~= C

SCOR_TNG CC ~ x G =

1=NONE 20=MODERATE M

o ~ cr c E- cr E-+ z c ~, E- c 5=TRACE 30=S EVERE c~ c c c; Cn c4 cn w M c ~=: cn

10=MILD liO=INCAP . x ca a cc c~

COUGH

SPUTUM ~ D I` ( b 10 /0

SUBST E RNAL SORENES S

OR AWARENESS

SORE THROAT

(or HOARSENESS) I I I J ~ ~ ~ I !

SHORTNESS OF BREATH ~ ~ (l ~~ ~ ~` ~~ (~ ~ J ~~ ✓

NASAL DISCHARGE /

CONGESTION

'~ I ~ U lJ

WHEEZING ~ )_ O

IO

~_O ~ I v I D a~ ~ ~ (~

C3EST TIGHTNESS /

RESTRICTION 1/0

FATIGUE

U (~

I I ~ I I I ) I /

~ f

HEADACHE I I ~ I /

FRONTAL : NO YES

7 YE IRRITATIO N

OTHER SYMPTOMS

(rTST~ 1 I I

I I( ( ~ ~ ` 1 "

symptoms & discomfort V1 AI1 ~

ted several hours /~~

\ I\ ~C+ I • ~

~ Y1^ ,''\V11

1

~

;ld they cause you to :

: " er to A-Ei )

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 productivitr

( * occupation, schoolwork, critical househo ld duties )

Stay at home sick(lose sick time from work r

Visit your physicia n

Visit an emergency room ~
~u3~ :C : NO

p.69

DATE ~2

I = -

COND . 5 cr ~ - ~ z z _

w H H

SCORING

1=

cn x <

:J0NE 20=MODERATE M C=

5=TRACE 30=SEVERE r4 a~-. o G~_ m cc w CO o F ~

10=MILD 4O=I_1CAP . ~" x y` x x W co

3 L7 C-+ Cr L cL L CC = CL p., C c=

COUGH f ~n

SPUTUM

SUBSTERNAL SORENES S

OR AWARENES S

SORE THROAT ` 1 I

(or HOARSENESS )

SHORTNESS OF BREATH

NASAL DISCHARGE/

CONGESTION

W HEEZIN G

=3EST TIG H TNESS/

R ESTRICTION 1 0

FATIGU E

HEADACHE

FRONTAL : NO YES ~ I r

SYE IRRITATIO N

D TRER SYMPTOMS

(LIST)

~ - - ---- - ~

symptoms & discomfor.t

- ed several hours ,

_d they- cause you to :

er to A-9 )

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{ activit y or level of productivity

( * occupation, schoolwork, critical household duties )

Stay at home sick(lose sick time from work)

Visit your physicia n

Visit an emergency room
p 70

S E J C T . -, "1r0

DATE

1 c"- ~> / - L-' L C

SCORING

COND . o

F w E- =

a =

_ F C =

O C G Cz

Z

cn cn

: C

x E - -

1=NONE 20='4ODERATE ~

5=TRACE 30=SEVERE ~

1. p _ C U C

C

__- co

Cr: ~ ~ w

M

~

10= M ILD L O=INCAP . ~'' x H x w x w x w

~ w rr w ~ = rr w c~ ~ a C c ~i-

. ~. _ c.

COUGH / ~ ( I f f '

SPUTUM

SUBSTERNAL SORENES S

OR AWARENESS I I j ~ /

SORE THROAT (

(or HOARSENESS )

SHORTNESS OF BREATH

NASAL DISCHARGE /

CONGESTION LJ~ )

W HEEZING 1 /

CHEST TIGHTNESS /

RESTRICTION ~ ~ I !✓~

.~

FATIGU E

HEADACHE /

FRONTAL : N0 ./ YE S i ~ ~ O

EYE IRRITATION l

OTHER SY M PTOMS

(LIST)

symptoms & discomfor.t

ted several hours ,

ld they cause you to :

:ter to A-9 )

Decrease ootional 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 productirity

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

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

Visit your physicia n

Visit an emergency room
p. 71

DA-'

~- COND .

z

SCORTNG a z z ~ cn N ~

7_- JONE 20=_~fODER-TE o '- - = c

C

5=TRAC E 30=SEVERE c:. 0 C_.~-, w

Cn

z E. E- Q::

10='~IILD H O

L O=INC '?P C+ X

. ~ X ~= w cc C

c~

COUGH

I J

SPUTUM

SUBSTERNAL SORENESS

OR AWARENES S

SORE THROAT

(or HOARSENESS )

SHORTNESS OF BREAT'~ ~ -

/

NASAL DISCHARGE /

CONGESTION

1 i

WHEEZIN G

CHEST TIGHTNESS/

RESTRICTION

F ATIGUE

HEADACHE

FRONTAL : NO ~ YES

L'YE IRRIT?_TION

OTHER SYMPTOMS

(LIST )

Symptoms & discomfort

ted several hours ,

l d they cause you to

=er to A- Fr )

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 r

Visit your physicia n

Visit an emergency room
p. 72

G?O :JP (I- (,U

T N0 6 ~ 24

DATE

i r E" ~" U U z z

COND . . 0 3 ~-. ,~ H a z w ~

w a

~-. w a w w w -,

E,

x rt z

a ¢ ¢

SCORING a = r . F, M M 1~i 1~- w ^¢ V C 1=N0NE 20=MODERATE M E-' ~ ri

SFT~ACE 30=SEVERE w Fo-. ~ w co ~ w coE 0 Cl:

10=MILD 40=IBCAP . 3 W X 04

W a

0.

a a

COUGH

SPUTUM I I 1

SUBSTERNAL SORENESS E

OR AWARENESS

SORE THROAT

(or HOARSENESS )

SHORTNESS OF BREATH I ~ I

NASAL DISCHARGE/ rn /~

CONGESTION !~V C0o /oO

WHEEZING

CHEST TIGHTNESS/

RESTRICTION

FATIGUE I

HEADACHE

FRONTAL : NO YES

EYE IRRITATION

OTHER SYMPTOMS

(LIST )

If symptoms & dis-comSort

lasted several hours,

would they cause you to

(Refer to A- H

A . Decrease optional or recreational ctivity List

B . Take additional medicatio n

C . Be unable to perform the maximum amount of work t at you ' could normall

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 vork)v

G . Visit your physicia n

H . Visit an emergency room
p. 73

G30 :JP

SUBJECT NO .

DATE

COND . 0 3 ~+ ~, E a a

E+ U o x =

~+w o w w w » . ,~ a _~

SCORING W= ~-r r i H r- ~ rr W - U L `o a Z `n M X a x

l=NONE 20=MODERATE Y o E' Q E., E E+ z e

W

E-4 SFT,RACE 30=SEVERE 0 co w co W co cr

10=MILD bO=IIICAP . w x '-' w x w x w a. x a c

s w ca w rc w ¢ w ac x a w a

COUGH

SPUTUM I I f

SUBSTERNAL SORENES S

OR AWARENES S

SORE THROAT I I

(or HOARSENESS )

SHORTNESS OF BREATH

NASAL DISCHARGE/

CONGESTION

WHEEZING O f(~ ~ J Q ' S f

CHEST TIGHTNESS /

RESTRICTION (

FATIGUE I I ~ I

HEADACHE

FRONTAL : NO YES

EYE IRRITATION I

OTHER SYMPTOMS

(LIST)

di s-comfq-r.t I I Ef symptoms &

lasted several hours. ,

would they cause }rou to :

(Refer to A- H

A . Decrease optional or recreatio al 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 1d duties )

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

G . Visit your physicia n

H . Visit an emergency room

- -- - ----------
p. 74

GROUP IX 1 n ~ ~~ ~(~. C~(

SUBJECT NO .

DATE

EH

H H Z

H U o z

:Z (~]

COND . , a H H H H w

o a F a

H w o w w w H H ~

a

.] - ¢

SCORING z z m m M x ¢

H H H H H H w ()

1=NOIIE 20=MODERATE o E' U Q

5pT,RACE 30=SEVERE W a o w m m m o w ~

10=MILD 4 0=I14CAP . °° x '"' x w k w ~e w a rs o 3 w cr w rc w cc W rc ~ w a

COUGH "o o~3

SPUTUM

SUBSTERN'AL SORENESS

OR AWARENES S

SORE THROAT

(or HOARSENESS )

.SHORTNESS OF BREATH toV

NASAL DISCHARGE/ ~ ~ ~ /fl ro I /,~ J ~ M /)o

CONGESTION

WHEEZING

CHEST TIGHTNESS/

RESTRICTION

FATIGU E

HEADACHE

FRONTAL : NO YES_

EYE IRRITATIO N

OTHER SYMPTOMS -

(LIST).

?f symptoms & disromfprt

lasted several hours- ,

would they cause

(Refer to A-H -

y1 ou to : ~

A . Decrease optional or recrea ional activity Li t

B . Take additional medicatio n

C . Be unable to perform the ma imum amount of work th t you ould normally

perform

D . Turn this workload level dovn(disregard fatigue )

E . Be unable to perform your usual vork• activity or level of productivit y

(* occupation, schoolwork, critical househo Id duties )

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

G . Visit your physicia n

H . Visit an emergency room
p. 75

GROUP

SUBJECT NO .

DATE

E" H (~

H H

COND . o ~ -+ H H E

F"w c w w w H F••i ~

SCORING 04 a z ~ M ~_+ m H x

~+ = M H H F-1 H H w

1=NOftE 20=MODERATE w E'

5=T,RACE 30=SEVERE w~ C w m w E10=MILD 4 O=I 3CAP .

W x '-' X w x w >e w n. a

a w cc aa rs r w x t,~ - ra ~ a

COUG H

SPUTUM

SUBSTERNAL SORENESS

OR AWARENES S

SORE THROAT

(or HOAR SENESS )

SHORTNESS OF BREATH p~ ('

NASAL

ONGESTIONHARGE

/

C

~

o

/

folio

f ^

O /0 )

m

WHEEZIN G

CHEST TIGHTNESS/ • ; O I_ ~

RESTRICTIO N

FATIGUE

HEADACHE

FRONTAL : NO YES R O

EYE IRRITATION

OTHER SYMPTOMS

(LIST )

LP symptoms & dtscomfo_r,t

lasted several hours . ,

would they cause you to :

(Refer to A-ff

A . Decrease optional or recreational activity List

B . Take additional medicatio n

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

perform .

D . Turn this workload level down(disregard fatigue )

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

(* occupation, schoolvork, critical househo id duties )

F . Stay at home sick(lose sick time from vork F

C . Visit your physicia n

H . Visit an eWe=geacy room
p. 76

-- - - -- -- -- ----- ----- - ~~~~~

GROUP X} l~ + ~ ~~ ~) V

•

SUBJECT NO

. JI /

DATE

E., ~ w v c

COND . " a

O 3 `-

H w o w w w H ,~, a

~-+ ~. ~. a

a

SCORING

1=-HONE 20=MODERATE

a~ z °'' W

M F' 0 v c~ ~

5jxT,RACE 30=SEVERE w

C)

. w

E~

ca

E.

Co o w ~ ~

10=MIi,D uO -INCAP . X x w x w >e w a a o C

w rr w ~ w a w ac ~ a a

COUG

H SPUTU

M SUBSTERNAL SORENES S

OR AWARENESS

SORE THROAT ~ I ~ f f

. (or HOARSENESS)

IJ IJ

SHORTNESS OF BREATH

NASAL DISCHARGE/ /~ ~J ~~ ~ f^ J r

CONGESTIO N 1 0

WHEEZING i f fn, 1 ~ I ~ 1 , (

CHEST TIGHTNESS /

RESTRICTION

FATIGUE

HEADACHE j I

FRONTAL : NO YES ~ ., I + ( I

EYE IRRITATIO N

OTHER_ SYMPTOMS ~ ! ~ ~ f I (

(LIST) J I

Lf symptoms & dis-comfo.r.t I I I I

lasted several hours., () J

would the

(Refer to A3r cause

H

you to : I

A . Decrease optional or recreationa1i activity List

B . Take additional medi l atio 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)y

G . Visit your physicia n

H . Visit an emergency room
p. 77

GROUP_ ~ ~ ✓ ~ -~( ~ 1~?I

SUBJECT NO .

DATE

~ z z w

E" H ~ z z

COND . 0 3 ' H w a

H w 0 w w w H H ,a] -¢ 4

SCORING a~ H H H H H Hz M M H H >e a s

w - v c.~

1= N ONE 20=MODERATE M SC O Z (L E~ CC E-GL E 2 U [.~

5PT,R4CE 30=SEVERE w M ~ w ca cc w co a w M

10=MILD 40=I14CAP . °q x '"' x w x w x w w X a c

s w rs ~ w c~ m a w ac a w a-

~

COUGH

SPUTUM • ~ ( I

SUBSTERNAL SORENESS

S I OR AWARENES

SORE THROAT

(or HOARSENESS )

SHORTNESS OF BREATH ~ O 1

NASAL DISCHARGE /

CONGESTION

f~

WHEEZING

CHEST TIGHTNESS/

RESTRICTION

FATIGUE

HEADACHE

FRONTAL : NO YES I f

EYEIRRITATIO N

OTHER SYMPTOMS I UN~~, I I I

(LIST)

C :~~,t . ~yE~ 1 I(

-4 E)

If

lasted several hourssymptoms & dis-comfor,

.t I

vould they cause you to :

(Refer to

A . Decrease optional or recreational activity List

A-a) L

T

B . Take additional medicatio n

C . Be unable to perform the

perform •

maximum amount of vork that you could normally

D . Turn this vorkload level dovn(disregard fatigue )

E . Be unable 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 vork)v

G . Visit your physicia n

H . Visit an emergency room
p. 78

-- - - ------ -- -- - - ~`~

GROU P

SUBJECT NO . 2~{

DATE ~~ aE M C C z =w

COND .

O 3 ~••~ w .3

F-1 w o w w w M, HE,

,

SCORING a z M M m M x x1=ftONE 20=MODERATE a ~ E-'

E~ 5''-T,R4CE 30=SEVERE w a~. ~ W m w E

co

we a

E

co

" z

w x ~, x w x a a°, w c~

10=MILD 40=IlYCAP

. 3 w cc w rc w rc w s ~ pa p° c

COUGH

SPUTUM 1

SUBSTERNAL SORENES S

OR AWARENES S

SORE THROAT I J r

( or HOARSENESS) Jl /

SHORTNESS OF BREATH ~ S 1

C~iO s' S S

NASAL DISCHARGE /

CONGESTIO

N WHEEZING I

t

CHEST TIGHTNESS/

RESTRICTIO

N FATIGUE ~ I ~

HEADACHE ^ I

FRONTAL : NO YES

EYE IRRITATION I

OTHER SYMPTOMS I I

(LIST )

If symptoms & dis•comtor-.t

lasted several hours, W

would they cause you to :

(Refer to A-$

A

B

. Decrease optional or recreati nal activity List

. Take additional medicatio n

1 I

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 vork• activity or level of productivity

(* occupation, schoolwork, critical househo ld duties )

F . Stay at home sick(lose sick time from vork F

G . Visit your physicia n

5 . Visit an emergency room

cz~
p. 79

.

GROUP

SUBJECT NO .

DATE ~ - ,C a

F H w ~

w

COND . 0 3 Hz W w

~, w o w F

SCORING a z M H rwn ,~ ~ H Xa ~

1=NONE 20=MODERATE co El ~'

5=T~tACE 30=SEVERE w 0

~ w ~ w ~ w ~ o

10=MILD 40=INCAP . ~~ x x w x w ~e w a a a

~ w ac w a w r~ w , rx ~ a, Q

COUGH ) (

I

SPUTUM ~ ~

I ~ I I I I

SUBSTERNAL SORENESS I I

OR AWARENESS ~ ,

SORE THROA T

(or HOARSENESS )

SHORTNESS OF BREATH

~

J (~ I

NASAL DISCHARGE /

CONGESTION 3

,0 10 / n / ~ `~/,,-o

WHEEZING

1 ~ 1

CHEST TIGHTNESS /

RESTRICTION 1 f I I ~ /~

1 J

FATIGUE

1/01 1 1 1

HEADACHE -~~ ~ I I I ~ I

FRONTAL : NO YE S

EYE IRRITATION ~ I I I I I I~ I

OTHER SYMPTOMS I / I + I I II I

(LIST) I I

If symptoms & discomfort I I I I ~~

lasted several hours ,

would they cause you to :

(Refer to A- 8

A . Decrease optional or recreational actiwity Lis t

B . Take additional medication ` I I !

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

perform

D . Turn this workload level down(disregard fatigue )

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

(* occupation, schoolwork, critical househo ld duties )

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

G . Visit your physicia n

H . Visit an emergency room
p. 80

. - --- -------- ----- ------ -- -- -- - -----~'y~~~

~

SUBJECT NO

DATE

F v a

H H Z' y [

z

~

CO ND . H w

C 3

.~

H w o w w w H H a a E,

SCORING a~ z `n m "" m H x ¢

(L = H N M H N H W 5 . U

1=-NONE 20=MODERATE Se o s a E E• cc E z E

00

., •

5"=TFACE 30=SEVERE w w o w m w m w m o w

10=MILD 40=I14CAP . x w x w x w a x

3. w rs w c~ w x w x ~ a a

COUG

H SPUTU M

SUBSTERNAL SORENES S

OR AWARENESS

SORE THROAT

(or HOARSENESS)

SHORTNESS OF BREATH

NASAL DISCHARGE/

CONGESTION

WHEEZING

CHEST TIGHTNESS/

RESTRICTIO

E N FATIGU

HEADACHE i \ ~ ~ \ r ~~I

FRONTAL : NO YES ( I l

i (

EYE IRRITATION i

OTHER SYMPTOMS

(LIST) 1 I

' - - If symptoms & dts-comtvr.t

lasted several hours- ,

would they cau s e 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 at home sick(lose sick time .°rom work)

G . Visit your physicia n

H . Visit an emergency rcom
p. 81

- ~ • : ;

,~ - 'r~~:l~"-^~''-t-•'- -

-r:

♦t'~:~W ~ . I

- CT AO.~

E

t ~ C7 C7 Z z

t~ z z w ~?

/ 0 3 r' `~ f, H a a ~ ~ M W a

;,~ ~ .`'= .°h+ w o w w w H F. a ¢ 4

x ¢ .- -

SCORING N M F-1 1-1 N H w x. U

1=ffONE - 20= M ODERATE Se o s rt E+ rt F+ a

M E' v EEH E+

5*T,RACE 30=SEVERE w M. C w m w m w M o w m ~

10=MnD 4 0=IIICAP . w

X '

-4 x x w k w a x o a

a w x csa w cc w rc ~ a a.

COUGH S ~ ~/ ~ I I O

/~

SPUTUM

1

v

SUBSTERNAL SORENESS I r ~ <

OR AWARENES S

SORE THROAT I ( ( `j

(or HOARSENESS) ~ l 1 ✓

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

NASAL DIS

COAGESTIOAHARGE/

~ ~ ~ ~ O I O ~ ~ ~} /oFi

WHEEZING ' ~ I ~ t I I I

CHEST TIGHTNESS/ <

RESTRICTIO N

FATIGUE I I i ~ 1 /

HEADACHE

FRONTAL : NO YES S

EYE IRRITATION

I ~

OTHER SYMPTOMS

(LIST)

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 perform the maximum amount of work that you could normally

perform

D . Turn this workload level do vn(disregard fatigue )

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

(* occupation, schoolvork, 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 - n _ .-~ . - - _ - _ -- - -

• ! ~1/+. I /~ ~ '~~f

T 110 . C

~ w Cz

~

:

E- H C7 0 x Z

~- o sH w o w w w H H a a ¢

F

x x z m m H m H x a x =

S CO~R I NG O+ .-~ H H H H H H W x• U

ONE 20=MODERATE E' ~ U F Sa o x t~ E• E• cL F E., Gr

g~T;RACE 30=SEVERE w R: o m m w M ° Wa x 0M

.

10=MILD 40=INCAP .

w X '' x w w w o

3 w x w rz w cc w x o a a

COUGH 20 l0 ~ id

SPUTUM I I V ~D ✓ Ir~,~~ ~v 1 U l~ `~

SIIBSTERIIAL SORENES S

OR AWARENESS l J ` > > J

SORE THROAT

(or HOARSENESS) . ~,

SHORTNESS Q V

RASAL DISCHAR,(~ ;

~ O - lJ 0,20 2-0 CONGESTION

~ (

.

WHEEZING

CHEST TIGHTNESS /

RESTRICTION Z~

/f~

FATIGUE

HEADACHE r

FRONTAL : NO YES 1

1

I U 1 IJ

EYE IRRITATION

OTHER SYMPTOMS / ' I !

(LIST )

If symptoms & dis-comtvr.t

lasted several hours ,

would they cause you to :~- ' ( f

(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 dovn(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 uork)

G . Visit your physicia n

H . Visit an emergency room
-- -~--~-.~ - _ -- -

- ~ , . ~ ~` +. ~~ •~ 1

CT N0 .

(i .

E, H c~ o z =Cz

z w

02fD . a ~ ~ ~ E a a 0 3

~-. w o w w w F-+ ~-+ a ¢

c~ x z m m m r-~ >e a x

SCORING cn, _ • ~-, H N ~, ~• w , L,

1~ipNE 20=MODERATE Eo

Ex , a E, a E, F,

5sT,RACE 30=SEVERE w a: cr w m w m w CO w

10=MILD kO=IIICAP

. w x `' x w x w x w a cn o

a w x w a w rt w x ~ a a

COUGH

SPUTUM

SUBSTERNAL SORENESS

OR AWARENES S

SORE THROAT

(or HOARSENESS)

SHORTNESS OF BREATH

NASAL DISCHARGE/ I

CONGESTION J 0 r10 ~ -~-o

WHEEZING ( I ~ /~

CHEST TIGHTNESS /

RESTRICTION ~ I~ CI I O ~ ~

FATIGUE

HEADACHE

FRONTAL : NOYES,>- I ID , ~ (J

EYE IRRITATION

OTHER SYMPTOMS

(LIST) 1 l 1

Lf symptoms & dis-comf(P r.t

lasted several hours,

would they cause you to :

(Refer to A- $

A . Decrease optional or recreational activity List

B . Take additional medicatio n

C . Be unable to perform the maximum amount of work that you could 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
4 . .

AV I"-

NO .

g ~~~ ~

`l7r'

~'\ o w ~ c

E-4

H HH U ~ 2 z z w z

OgD . ('Y H H H H W a

0 3 E .

H w o w w w H H

-4 a a

a

m H m x a

SC ORIlYG ~ a z `n - Il. H H H H H H W = . V C

1=-NONE 20=MODERATE (n E" 0 0 U

SG O ... rt E fz E rc E z E, E

5=T,RACE 30=SEVERE w tr. 0 w CO W m W m o W

10=MILD 40=INCAP . W xW cc w z W ,z w cc = a a

$-4 x x W x w a a o

.

COUG H

SPUTUM [O to 10'o Iv jV tO L~

SUBSTERNAL SORENESS

OR AWARENES S (

SORE THROAT

(or HOARSENESS )

SHORTNESS OF BREATH J ~ ~ ( l l r

SASAL DISCHARGE/

CONGESTION

WHEEZING

CHEST TIGHTNESS/ JO T~ ( ~

l

~

I

/,

RESTRICTION 0

101 l (~ `

FATIGUE

HEADACHE (~1 J 1 ' I J I '

FRONTAL : NO YES GS✓ f J

EYE IRRITATION ( ~ ~ ~ ~ I 1 I

OTHER SYMPTOMS 1 ~ ~ )

(LIST) 1

If symptoms & dis -comfort

lasted several hours- ,

would they cause you to :

(Refer to A-H tl-4 A . Decrease optional or recreati nal 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 dovn(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 vork F

G . Visit your physicia n

H . Visit an emergency room
p. 85

I

C T ~ ~

3 ~~'~ o

E v

w

H H z z W H v c~ z z~

0 BD . Q 3 ,~ H H [r] a

H W O W W W H H a ¢

E

a Z tA CA

¢

SCORING M ?C

1 -N ONE 20=MODERATE

=

M

H r, H H H W ¢ V U

E U 0 0

5xT~ACE 30=SEVERE w c E

0

.- o w m w ~ w to a w

M E10=MILD 4 0=I14CAP . x X W W cc W X W X W a a

to W x W z ~ a G,, a.

COUGH ~ )

/ 1 J

I

SPUTUM {~• ~ ~ ~ ~ ~ + ~ `C

SiJBSTERBAL SORENESS l ~

OR AWARENESS ' '' I I I /~ S

SORE THROA T

(or HOARSENESS

OF BREAT ) SHORTNESS H

NASAL DISCHARGE/

CONGESTIO N

WHEEZING

CHEST TIGHTNESS /

RESTRICTION 1 1

FATIGUE I , / f

HEADACHE

FRONTAL : NOV YES

EYE IRRITATION

OTHER SYMPTOMS I ( ( Q J

(LIST

f symptoms & d=s-comfQr ) I t

lasted several hours-,

would they, cause you to :

(Refer to A- H

A . Decrease optional or recreational activity List

B . Take additional medicatio n

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

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
"c.."~1 • r !

CT fto .

[

-4 H C7 C7 Z

OND

. E-+ a a

° w o w w w H H a ¢ <

SCORING

~~ z m cr' H M x ¢ -- -

a= H ~, H H H H w s. c~ ~

E 1=NONE 20=MODERATE m E'' °

be 0 s G~ E cc E-4 ac E z E,

5TT,RACE 30=SEVERE w tx a w CO w m w m 0 w m

10=MILD 4 0=INCAP

. w" '' x w x w x w a c~ o

3 w x w cc w a w a = w a

COUGH / 0

SPUTUM f- v

SUBSTERI4AL SORENESS ~' I I I ~ I +

OR AWARENESS ' ` Il I

SORE THROAT l I I

(or HOARSENESS )

SHORTNESS OF BREATH 1o/c h)0

) /,C) /C)

NASAL DISCHARGE/

CONGESTIO N ~ - f ) -

WHEEZING / l J ~ O ~ O C~ ~G

' I I

CHEST TIGHTNESS /

RESTRICTION

FATIGUE

/ ) 1 1 I ~

HEADACHE

FRONTAL : NO /YES_

EYE IRRITATION I Iy ~ ~ ~ ~ _I I ~

OTHER SYMPTOMS

(LIST) I I

If symptoms & dts-comSq-rt J \ ,

lasted several hours- ,

would they cause you to :

(Refer to A-Er

A . Decrease 'Optional or recreational activity List

B . Take additional medicatio n

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

perform

D . Turn this workload level dovn(disregard fatigue )

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

(* occupation, schoolwork, critical househo Id duties )

F . Stay at home sick(lose sick time from vork F

G . Visit your physicia n

H . Visit an emergency room
p. 87

.

.a .,,, - ,_.. ., " - :r. "• : t:i,>~==--•.,•-. . ,,y, .

. ^,i. ----- -- - _ - -- - - ~.... ..~ . .~-_ .

Ali `=x:o : .7~Tt~-f:o,i r' ~' a.~ d•

uliti

~'.

-5/7

Ju ,t.t o W

0~• 0 3 E a a

I ,

E' H z z w W

..., H H H w a a

a

H W 0 w w w H F•1 a ¢ a

t~a= z co m H co H YC a Z U

SCO ING (y = H H H H H H W X U

1=i~10NE 20=MODERATE o z a E CA E U U U E-~ f' ., E• X E• z E~ L

5=T♦pA C E 30=SEVERE W cc co co o W m H `, W X H X W X W W G. O o 0.

10=MILD 40=INCAP . W cs w cz w a w a ~ a a a

COUGH

-, C 2-6 1 ))

SPUTUM

C7

SUBSTERNAL 0

SORE THROAT

~ l

(or HOARSENESS )

10 ~ I l ~ ~ • I / ~ /

SHORTNESS OF BREATH

NASAL DISCHARGE/

CONGESTION

WHEEZING

CHEST TIGHTNESS/ i ~ ` • ~ ~

RESTRICTION

FATIGUE 3~/

HEADACHE ~/

FRONTAL : NO /~ YES_

EYE IRRITATIO N ~>> i ~ ~ I

OTHER SYMPTOMS

(LIST)

If symptoms & discomfor .t

lasted several hours, ✓ ~ _ `_

vould they cause you to :~ ,

(Refer to A- H

A

. Decrease optional or recreational activity List

B . Take additional medicatio n

C

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

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 vork)

G . Visit your physicia n

H . Visit an emergency room
p. 88

- ~

.~ .+ .nrn1P(~

Dedsioa Focus Inco7'porac~

Table C-6

PHYSIOLOGICAL AND SYMPTOM RESPONSES OF SUBJECT 726

A MINIMAIJMILD ASTHMATIC, GROUP # 3

SR .. SCOMS f04 3lAJECT N.~ER 724

< . .Intr i/.t•t~ . .te .•cic - rr . .r !3)

ROVO ~1 $R•. SCORES

E .r~1 SR• . Inc . . Ls" SR .• Iecr .

E•riT l•t. Cerr.ctN

$02 cow "11 EARL• LATE SR.. Incr . SR. . Incr . Ec•rc7•. AI•n. Ec.rcl•• Al .,.

4• C.411 • 424 i .321 1 N1 •.44 s

1 .2 i.444 7 .337 4 .41/ 4.l32 - 4 .11t 4.14•

• .4 i.71• 11 .42 0 )i .333 4. 9" 3 .2N •.494 1.722

1 .4 4.49 2 19 .111,11 22 .6E 6 3 .2/i 3 .t12 2 .7N 3.3~1

ROIJO 0 1 SR• . SCORES

£.r17 SR•. Iner . L.ts SRs . Iner .

E•r17 l•t . C.rrKw f•r C•rr .ct.~ ( .r

S02 COpC PRE EARLY LATE SR•. Iner . SR•. Incr . E urci• . Al .'.. Ea.rci•. Al .n~

4 .• 4.{1s •.nH

1

.24 6 4 .423 4 .744

• .2 7.4N 7 .717 t .{c2 1 ./~t 1 .~N I.qt 1.Nf

• .4 f.N• 11 .cN 7 .417 1 .9111 1 .422 1 .1li •.233

/ .4 4.7N 21.J17 1f.413 1 . 188 3 .24 9 4 .24i 1.4i4

C0/m 1lEO R9tJ10S SRN SCORES

Ear17 SRs. Iner . l•t. SR*- Iner .

E•r17 l•ta Grr.c6N i.r C .rr.ct" f .r

$02 COYIC MtE EARLY LATE SRs . Iner . SR. . Iner. Easreiw At . ... E.•rcl.. At ...

/ .4 i.lll •.412 ~,2~7 4 .442 •.436

• .1 +.4111 7 1 3 2 4 .2rc 1 .14e 1 .2u •.u . 4.s23

4 .4 4.7f2 it 440 13 .i7f 1 .4f3 1 .414 •.431 4.~74

4 .4 4.741 24,721 1111130 4 .144 3 .4 64 3 .44 2 2.422

f£Y1 .1 iCORES ROR SuRJCCT nMER 774

(• •~nl . .t/.114 ••an.ytle - rr•.r N)

ROWO ~1 fFv1 .i SCORES

E4r17 fEV1 .4 D .cr . L .t. FEYl .i O .cr .

Gr17 l•u

S0

C•rr .ctN I•r C•rr .ct•1 Lr

2 COMC ~RC EARLY LA TIE FEV1 .R O~er . FE~'1 .4 0«1 . E..rcl .. Al ... C ..rct .• Al .n•

s .• s.4N 3 .210 3 .4N •.444 4 .i3 2

• .2 3,47• 3 .1M 3 .1ar 4.117 4 .w 4. 01 0 • .su

I .4 3,.74 l .334 2 .444 •. 844 0 .114 -0,0440 IT

/ .• 3,4N 2 .442 2 . 642 i.343 4 337 4,21.

0

. 301

ROtlO # 2 FEVl .i SCORES

E•r17 fEYI ./ O .cr . l•t• FCY1 .4 D .ar .

Early Litt. C.rr .ctN f .r C .rr .ct .4 fv

US cow PRE EARLY LATE FEV1 ./ O~cr . FEV1 .4 O.cr, E. .rcl "

Al .n . E..rc t w Al ....

i .• 3.i14 • .iN 3 .42tJ -4 .411 / .12•

• .2 3.744 3.401 l .41i 4.437 i .13{ 4.14 0 • .N1

I . . 7.IN 3 .2N 3 .1N •.147 • .)F1 4.1i. •.13t

• ./ 1.4N 1 .iN 2 .3N 4. 93N •.3N I.i4{ 0 .331

C03i•IIED R01JOS FLVI .i scam

Lady FEV1 .4 O.er . l•t. FEY1 .4 O+er .

CGrt7 L•t. C .rr~ct../ f .r C .rr .ct•4 f .r

iQ7 CONC FR( EMIY LATE iEY1 .4 O.cr . fEY1 .4 D- 1:0-J . . At .+ .. At .-

9{ .41 .41f 3 5 .4N • .13f i ./21

• .3 i.Ni 7 .3N 3 .3ii •.472 • .N2 •.433 •./33

/, . 3.43i .496 3 .43f •.H1 4.1 63 4.462 •.134

• .4 ~.7N 2.1 0 1 2 .4 6 1 4.41 111 4 .341 /.300 0.317

C-22

R)Fi3lACC W
p. 89

• ,a

"ROUP

SUBJECT NO .

DATE ~ ~- o w w E~ w v c~

-~ U c7 z z

COND . 6 ~ H H H H w a .a

o a

H w 0 w w w H FH-i a ¢ ¢

SCORING . ~ x z cn cr~ ' M ~-' x a H .;. =

~, H M N H H (x] ¢ U U

1=NONE 20=MODERATE co E' U

5 ;~T~RACE 30=SEVERE w ra Se o F+ rz F+ rz E-4 z E-, Ec~

; ~ w co w co w ca 0 w m H

10=MILD hO=INCAP .

PQ

3 w cc w a w ~ w x ~ a a a ca X x w x w x w a cc o 0

COUGH

SPUTUM

SUBSTERNAL SORENESS

OR AWARENES S

SORE THROAT

(or HOARSENESS)

SHORTNESS OF BREATH

NASAL DISCHARGE /

CONGESTION 1 /

WHEEZING

CHEST TIGHTNESS /

RESTRICTION ti

FATIGU

E HEADACH E

FRONTAL : NO YES f

EYE IRRITATIO N

OTHER SYMPTOMS

(LIST)

If 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 amount of -work that you could --c-mally

perfor m

D . Turn this workload level dovn(disrezard fatiaue )

E . Be unable to perform your usual work* activity or level of prec c vity

(* occupation, sc^eolwcrk, critical househo id duties )

F . Stay at some slck('_ose sick time from work

G . Visit your nnysicia n

H . V~s_t an eme eacy room
P

. 90~

GROU P

SUBJECT NO .

DATE a w ~If~'-OS W W 0

~/ H H z z w w

E-+ . H v U z Z

COND . o s 'r a a

H H H H w 7 a

H W o W W W H H .-a a Q

SCORING .

a z z m

LL H H H H H H W U

co H co H x <

U

1=NONE 20=MODERATE Se o = r~ F E~ °

X E• z E~ cc

5x'ISRACE 30=SEVERE w cs: W co w CO w w o w to co F- +

10=MILD 40=INCAP . x X

W w c~ w e w rs a a o

w x w X w a .~ o o a

. a co

COUGH

SPUTUM

SUBSTERNAL SORENESS

OR AWARENES

S SORE THROAT

(or- HOARSENESS) ( ( rl ~ ( I ` 1 ~ II

SHORTNESS OF BREATH , I ' I I ` ~ / ~

NASAL DISCHARGE /

CONGESTION I ( (

WHEEZING

CHEST TIGHTNESS/

RESTRICTION

FATIGUE ~ ~ ( I ( I1 + ~

HEADACH E

FRONTAL : NO YES

EYE IRRITATION I I / ( I ' ~ ~~~

OTHER SYMPTOMS -

(LIST)

If symptoms & disccmPor.t

lasted several hours,

would they cause you to :

(Refer to A-H

A . Decrease optional or recreational activity List

B . Take additional medicat4o n

C . Be unable to ner°orm the maximum amount of work that you coul

m d ner°cr

D . Turn this workload level down(disregard fatigue )

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

--, c__tical househo 'id duties f (* occupation, schoolaor' )

F~ Stay at home sick(lose si_ ~ime °rom worx)V

G . Visit your physicia n

H . Visit an emer q encv room
p.91

G R OUP

SUBJECT NO .

DATE J ' l E W v C

w

H U U ~

.7

Z

COND . ~ 0 3 H ~+ H H w ,~ a

H w o w w w H H a a

h a ,a a

¢

SCORING co cc

H w a - -

1=NONE 20=MODERATE co E_' o 0 0 ~ " o 0

5i~RACE 30=SEVERE w c c~ w co w co w ~ z co

10=MILD 4 0=INCAP . x W x W x w a ~ o o w

3 w rz w rG w r w rz a a a co

COUGH 5

SPUTUM f I ' ~ I ' ~ ( (

SUBSTERNAL SORENES S

OR AWARENESS l

SORE THROAT I I l ~ (

(or HOARSENESS) 5

SHORTNESS OF BREATH ' I I ( ( ( ~ ' ~

NASAL DISCHARGE /

CONGESTION

WHEEZING

CHEST TIGHTNESS/ 1 I ~ 1 ' I / ~ '

RESTRICTIO N

FATIGUE ~ I 1 ~ I ( I

HEADACHE I ( I t ~ I I I( ' ( I ~

FRONTAL : NO YES

EYE IRRITATION

OTHER SYMPTOMS

(LIST )

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 amount of work that you could normally

perform

D . Turn t his -workload level down(disregard fatigue )

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

occupation, school w or - , critical household u . t '_e=_ )

F . Stay at home sick(lose s-ick time from Work)v

G . Visit your 7~ hvsicia n

H . Visit an e m e--xe . _ z~~.m
GROUP ' ~ '`

~ ~ 1 i~ ~ ~ ,1~ ✓' ~ ~

SUBJECT NO .

DATE I ~~O~

{'/ w

o w c~

Er H U U z w

z

H H z z w a

COND . H H H H

o a t• a ,

W

H w o w w w H H a ¢ a

.a a

SCORING . CL H H H H N H W U U

z cn u~ H rn H x _¢ ~ x

1=NONE 20=MODERATE E' " Se o E

0 U °

- c E~ E~ z F Ea cc

5*T>RACE 30=SEVERE w a: 0 w cn w co w cn 0 w v~ m H

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

:D w a c

a

a w rz w rs w a w a a

COUGH -5-

SPUTUM h~ I S I ( ~ I ~ I

SUBSTERNAL SORENESS I

OR AWARENES

T S SORE THROA

(or HOARSENESS )

SHORTNESS OF BREAT H

NASAL DISCHARGE/ 1

CONGESTIO N

WHEEZING

CHEST TIGHTNESS /

RESTRICTION S

J / C

FATIGU E

HEADACHE ( I I I ~ ~ ~ /

FRONTAL : NO YES ~ f

EYE IRRITATIO N

OTHER SYMPTOMS

(LIST ) ~ ► I ~ I ~ 1 i

if symptoms & dzsccmiort

lasted several hours,

aould they cause you to :

(Refer to A-H )

A . Decrease o p tional or recreational activity Lis t

B . Take additional medicatio n

C . Be unable to perform the maximum am-cunt of work that you could norm ally

perform

D . Turn this wor~- '_oad level down(disrezard _`ati F ue )

E, Be unable t o perform your usual wor's * activi t y or level of -~ rcduc -. ivity

(* occu-D aticu, schoolwork, critical househo '_d duties ,

F, Stay at ho -me s'_ck(lose sick time from work F

G . V Ls it your c'r-:sicia n

H . Visit an eme-_ nc y room
p. 93

GROU P

SUBJECT NO

DATE O w ~ U

E~ H U U Z Z

z z w a

COND .

V/~

~ H H H H w n

o s E• a a]

F-1 w o w w w H H a ¢

a

¢

cc x z m m H n H x ¢

SCORING . a a H H H H H w U v

17NONE 20=MODERATE x o x a N a E• a ~, z ~ E. o

5=25RACE 30=SEVERE w w o w m co w cn o w m Cn "

10=MILD 4 O=INCAP . w x '-' x w x w x w a a~

a w cc w r~ w a w c~ a a

COUGH

SPUTUM

SUBSTERNAL SORENESS

OR AWARENES S

SORE THROAT

(or-HOARSENESS)

SHORTNESS OF BREATH S

NASAL DISCHARGE /

CONGESTION ( !

WHEEZING

CHEST TIGHTNESS/ 5- ~

RESTRICTIO N

FATIGUE

HEADACHE ~ I 1 i / I I '

FRONTAL : NO YES

EYE IRRITATION

OTHER

(LIST)

SYMPTOM S

?P symptoms & discomfort

lasted several hours, /y~+1 - --- - -- -

would they cause you to-

(Refer to A- H

A . Decrease ontional or recreational activity List (-4 c~ ~---

B . Take additional medicatio n

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

perform

D . Turn is work -"cad level down(disregard `a -. ;gue )

E . Be unable to perform your usual v ork* activity or level of roductivity

occupation, schoolwork, critical househol d c~ :es)

F . Stay at home sic k (lose sic k time from uors)v

G . V_s-it your rnysician

R . Visi ., an _=e--Fency room
p. 94

-A GROU P

SUBJECT NO .

DATE o H c~ ~ z

H H z z w a

W

COND . ~ H H H H w a a

H w o w w w H H a ¢

o F a a

a

SCORING a

~ z cn rr~ H v~ H x ¢ - =

I1. ~ H H H H H H W U U

1=NONE 20=MODERATE F' 0

~e O - cc E~ ~ E. ~ H z E, E+

51TIR ACE 30=SEVERE w rs: o w ca w co w CO o w CO

w H ~

10=MILD 4 O=INCAP . x x w x w x w a o o a

3 w . w rx w w rx a a actj

COUG H

SPUTUM ~ j ~ ( ( ( ~ f ' I (

SUBSTERNAL SORENES S

OR AWARENESS l I ) I ~ ( ' (

SORE THROA T

(or HOARSENESS) /1 )

SHORTNESS OF BREAT

H NASAL DISCHARGE/ ~ I ~

CONGESTION

WHEEZING

CHEST TIGHTNESS/ / r t

RESTRICTIO N

FATIGUE

HEADAGHE

FRONTAL : v0 YE S i

EYE IRRITATION / ' / / r ~

OTHER SY MPTOMS

(LIST)

?f symptoms & discomfort

lasted several hours, - - -

would they cause you to :

(Refer to A- H

A . Decrease o p tional or recreational activity List

3 . Take additional medicatio n

C . Be unable to perform the m aximum amount o_° work that you could normally

j erfc-- m

D . Tura this workload level dcwn(disregard fa -. igue )

E . Be unable to perform your u sual work* activity or level of produc -. :-rity

occ pation, schoolaor's, critical household duties )

Stay at home sick(lose sick time _ rom vo : ;i~

. . V 4- si t y our physicia n

H . Visit an emergency room
GRGUP .9A

p.95

SUBJEC T

DATE 3

~i ~ .,

.h~ o w w

Ei w U ~ i"~ U U Z z

COND . _~

o s

fZ H ~ Z W w ~H-+ H H w ,,~ a

H W W w H 0 W

E- H4 a ~ a

SCORING pa j z H H H H `n H y~ a U U

1=NONE 20=MODERATE ~ F_'

5=~RACE 30=SEVERE coi W

EH

~ ~ o w

U O

co CO

a

10=MILD ~+O=INCAP . w ~ W W a ~ a a°, a~

COUGH I I I I ~ J l I ~

SPUTUM

SUBSTERNAL SORENESS

OR AWARENES S

SORE THROAT

(or HOARSENESS)

SHORTNESS OF BREATH

NASAL DISCHARGE /

CONGESTION ( +

WHEEZING ( l I (

CHEST TIGHTNESS /

RESTRICTION I+ l

FATIGU E

HEADACHE ~ r

FRONTAL : NO YES

EYE IRRITATION

OTHER SYMPTOM S

(LIST

) ?f symptoms & discomfor t

lasted several hours,

would they cause you to :

(Refer to A- H

A . Decrease optional or recreational activity

B . Take additional medicatio n

C . Be unable to perform the :z aximum amount of work t hat you could normally

perfor m

D . Turn this workload level down(disregard fat_Kue )

E ., Be unable to perform your usual work* activity or level of nroduc --i v :A y

(* occu p ation, schoolwor k , critical househo _d d,-:ties )

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

Visit your physicia n

H . Visit an e mergency room
p. 96

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