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### p . 28,A7

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### p . 29, ,

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### p . 3~~'

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### p . 31

/UBJECT NO .

, DAT E ~ o w v ° E ,-, v o z z / H H z z w w_ COND . 0 3 E. H w o w :4 s7 H H a a ¢ rL rs z u~ m H cn ~-'x a SCORING a m H H H H H H w ~ U ~ 1= 1 OYE 20=MODERATE ~ E- E T~tACE 30=SEVERE w~ o w m w co w CO E 0 m o 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
) SHORTNESS

OF BREATH ~ 'i ~ ~ 1 ~ ' NASAL DISCHARGE / CONGESTIO N
WHEEZING If 1 I f ` J ( f I _01411 CHEST TIGHTNESS/ ~- RESTRICTIO N 

# ~ FATIGU E 

# A~=~ ► ' ' 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 ! ~, w w E M W v J COND . s , " H z Z w w O 3 -+ F, W a 1 i-+ w 0 w 4 a ~7 a cz x x v~ W w "' t a a SCORING X ¢ ~ . 1= 11 014E 20=MODERATE w S--TRACE 30=SEVERE w 0 M E E-4 e» c 10=MILD 40=I 3 CAP . w X k w X w w m o w ~ v~ ~ X w s w x w cc w x w x o a a°, a ~ COUGH 

## s7 SPUTUM SUBSTERNAL SORENESS OR AWARENES S

. ~ I THROAT



# , I I I I ~/~' I J ( orEHOARSEI7ESS ) V I 6 SH O IIESS 0 BREATH r I I l , I J ~ /~ ~ NASAL DISCHARGE/ ~ I CONGESTIO N

WHEEZIN G CHEST TIGHTNESS/ ' 

# 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 roo m ___--_-- -- ---- ---- -- - -- - ,~""

### p . 33



# -- -

~--- Q 

### 01j) GROU P SUBJECT N0 W DATE - a 0 r H C v z .~ ,- . H z z w w COND . H , H N w a ~ o a F a a ¢ H w o w w w H H a a {L fZ z U] co H m H X a SCORING (1. = H H H H H W ~ . 0 U l=NONE 20=MODERATE co 0 0 ~ v E¢ o x rz E+ X E- X E+ E+ m cc 5=BRACE 30=SEVERE w x co w M W m w cn o Cr] 10=MILD 4 O=INCAP . W X x w x Cr x Cr] P . X . o o a a w x w ~ w a w a o a a a Cr
COUGH 1 ~ , i I
SPUTUM SUBSTERNAL SORENES S OR AWARENESS 1 I SORE THROA T (or HOARSENESS )

SHORTNESS OF BREATH I ~ ~ ~ I i /1 NASAL DISCHARGE/ I 1 1 CONGESTION - /9~ WHEEZING 7 CHEST TIGHTNESS / RESTRICTION l j ` I ~
FATIGUE `
HEADACH E FRONTAL : N0 ~ YES ~•

EYE IRRITATION

~ OTHER SYMPTOM S (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 SORE NES S OR AWARENESS 1 1 SORE THROA T (or HOARSENESS )
3 ~ SHORTNESS OF BREAT H BASAL DISCHARGE/ 1 CONGESTION -1 - ,-, WHEEZING 0 v CHEST TIGHTNESS/ 1 ~ ~ 1 ~\ 1 I C I RESTRICTIO N
FATIGUE

FRONTAL : NO YES

EYE IRRITATION OTHER SYMPTOM S (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'

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. . . • yi~ .. .'- r .'~..'ai' S 9' .'.> k

; t t,

. _



# -~- •

~ `•~. - .i~~~"r ROUP SUBJECT N O DATE 5,3 Y f~, . r•C7 C Z Z ~ ~ H ~ y a w w_ COND . a ~ w o w w w - . ~, a ¢ SCORING z `n x _¢ - w V U 1= 9 ONE 20=MODERATE ~d a E ~ E y E Z c~ E E, 5,~= T.RACE 30=SEVERE w w c~ w m w m m o w co M w x o-, x w x w x w a rn o 0 10=MILD 40=I :4CAP . 3 w ~ w r~ w s w rt ~ a a a. COUG H

SPUTUM SUBSTERNAL SORENES S OR AWARENESS ~, ~ ( I
~ SORE THROAT - I (or HOARSENESS ) SHORTNESS

OF BREAT H NASAL DISCHARGE / CONGESTIO N
-WHEEZING I ~ ~ ~ ` I 1~ I CHEST TIGHTNESS/ `- I + I RESTRICTION I ~
FATIGU E
HEADACHE FRONTAL : NO YES
EYE IRRITATION ~ I I OTHER SYMPTOM

S (LIST) Ef symptoms & disromfpr .t ~ - . lasted several hours-, _ L vould 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 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 P ( C SUBJECT :40
. ;0 DATE / _ ~ v U z Z

ITiJ ~ ~ z z w w COND . 

### O a F a ~ w O w w w -+ ~ a a ¢ SCORING

_ co M M ~ x ¢ = ~ a~ H H 1 .=-N ONE 20=MODERATE co t! U v v `s O .- E ~ cL E E-E z E» E" 5=TRACE 30=SEVERE w cr ~ w Co w co w Co o w co - w x rr C 10=MILD 40=IYCAP . !C w x w X w a a o 3 w cc w a c~ Q w ~ ~ a a a COUGH I l ' I

SPUTUM SUBSTERNAL SORE NESS OR AWARENES S SORE THROA T (or HOARSENESS )
SHORTNESS OF BREATH \ J 1 I ~ ~ ~ ~ v NASAL DISCHARGE/ I I CONGESTIOI

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

- RESTRICTIO N
FATIGUE
HEADACHE l ( ~, ` I I I I FRONTAL : IIO YE S

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 w ork, 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 0 3 H H H H W ~ ; COND
. 

# -7' H W O W W W H H .] Q Q SCORING z cc z m m m `-~,z • 0 . . U H H H H H H W '•" ~J U M N U U U U 1=-NONE 20=MODERATE Y O S CC E+ E. X E-4 = F, E~ S~T.RACE 30=SEVERE w w v w m W m w m w 10=MILD 40=IYCAP
. w x . X w x w x W a . s o a ~ s w m w x w rc w c~ ~ a a a .~tY`_~ I COUGH I ' I ~ ~ t r
SPUTUM SUBSTERNAL SORENESS / i OR AWARENES S THROA T SORE (or HOARSENESS) I I I 1 I ' ~ ! I /
6PCM

ESS 0 REATH I I 1 ~ I ~ ! 1 V J~ NASAL ISCHAAGE / CONGESTION 

# _~ ~ ~ ► ~ 1 ~ f ~ ~ ~ WHEEZING 

# 5
CHEST TIGHTNESS / RESTRICTION
FATIGUE ' ~ I I
HEADACH E FRONTAL : IIO YES_

EYE IRRITATIO N 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
. ~ 3 r .7 r r . w o w w w ~ . -, a ¢ a SCORING z H H m 1=tTONE 20=MODERATE C4 E U 5=TIRACE 30=SEVERE w~ n w E" x w w M w m o w ca x P-4 10=MILD 40=I x CAP . x w x w a x a a w x w x w ac w a o, a / I COUGH ~ ) I I ► ~ ~ ~ ~ S PUTUM SUBSTERNAL SORENES S OR AWARENESS I I I I I . SORE THROA T (or- HOARSENESS )
SHORTBES~ OF REATH \ I 1 0 

### NASAL DISCHARGE/ CONGESTION
WHEEZING ~ ~ 

# D

~ I I I ID 10 )~

~ CHEST TIGHTNESS / RESTRICTION 1 1
FATIGUE ~ I I I 1 I 1 ~ ~ I ! / ~ I I

HEADACHE ~ I I f I ( I FRONTAL : 40 YE S il -

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 U v z z ~ H z z w W 

# 3 a H H H H w a COND . o s h a 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

I SPUTUM SUBSTERNAL SORENES S OR AWARENES

S SORE THROAT (or HOARSENESS) I ' ~ 1 SHORTNESS OF BREAT H 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 E- ~+ o o z ~ ~, -• z w

cc `, ~ . ~ N w a

_ COND . z o s E ~+ w co w w w ~, . a ¢ < SCORING x ¢ ~ - 1=tT0NE 20=MODERATE o E ~ E m F s F w m o w m 5=TRACE 30=SEVERE w a : d w m w c o 10=MILD ~+0=IYCAP
. W x x w x w x w r~ o s w rs w c~ w cc w cz ~ a a COUGH / ~ J f ! ( SPUTUM I i ~ l I, SUBSTERNAL SORENES S OR AWARENESS I I ( SORE THROAT 1 I J 1 ! { ~ (or HOARSENESS) I' ) I I ~ ~ ~ SHORTNESS OF BREATH NASAL DISCHARGE/
~, ;,,. . .. CONGESTIO

N WHEEZIN G CHEST TIGHTNESS/ 

# I 1 j ~ 1 ► v ~- RESTRICTIO N

. .~. , ~ 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 . 

# 3 ~LU ~US/ ~ ~ w w DATE o )S~ ~ w c~ v E H U U Z = L,/J-/ H H 2 2 w COND . a H H H H w a o a N a 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 v Se O s cC E ~ E+ c~ 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
: COUG H
SPUTUM . `-~
. SUBSTERNAL SORENES S

OR AWARENES S SORE THROAT ~ ` ~ s~- /1 1 HOARSENESS

) (o r
SHORTNESS OF BREATH NASAL DISCHARGE/ CONGESTION
WHEEZING 1 T- lo CHEST TIGHTNESS / RESTRICTIO

N FATIGU E

FRONTAL : 80_ YE S
EYE IRRITATIO N OTHER SYMPTOMS (LIST) ~f symptoms
- & dtsaamf CP-rt ~~- A 5C . A- '~~5,L lasted several hours- , vould the y 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 (q 0 DATE ~/- COND . F 1 ~ SCORING 1 '70 ' 0 ~ 30~g ~DERAT E -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 O SpUTUM = SU ~ r / f ~

F?SAZ OR BAwA ENSS OREHESS SORE THROA T ( or HOARSEBESS)

~I 5~0 NE SS 0 BREATH COGEST CHARGE/

10N 

# ~ WgVEZIRG CgEST / ~ ~ / / RESTRI TIORHESS /
FATIGUE gEADACgE l I I / ~ / L ! FRONTAL : ~ l !

NO YES

_ 

### EYE ~E IRRrTATIO~f ( LIST) MP TOMS ~ I I ~ I ~ I voui d Paev~r 1~#s-epmS Q r.t ( Repert ~oq cauy ~ 

# A o~u'to : Decrease C . Take additptiOaal or q

# b D . Perra~le to perfadicatiornatiOnal activ.i t

tb, ~ the ma Turn Z Y List E Be una torkl°ad level amount or uO r G . StaY c8~ Pation Pesh rm YOUr du ua G
. k that YOU cOUl d $ . 713 It Youome sick~iolKor k . c W°r~" ac~ati8ue) normallY Visit an e

meh gcIIC~a~ o

~ sick timectro m o~org iid duties)1 Of Product iPitY `-`"'.=~•~~ ;,-

„


# _ = = C'

# R OUP 

# ~ SUBJECT Y0 . DATE w r N U U z -
. • . ~ . N N z z • COND . a o s r a a H w o w w w H N a ¢ a SCORING ~ a z co an M H x a
= N H M H H W ,.~ U C 1=-NONE 20=MODERATE m U C .) ~ Y O E - 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 l 

# I 1 ~ ~ I ~ J ( + 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 E

- H v U ~ ~ U Z / H H Z 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

N WHEEZIN G CHEST TIGHTNESS/ ( 4 I + RESTRICTIO N
FATIGUE 1, i I I ~ I I ~
HEADACHE ' I I I ~ I FRONTAL : 80 YES 

# ! ' , ~ ~ EYE IRRITATIO N OTHER SYMPTOMS / r I I . ~ I I I ,) (LIST ) If symptoms- & discomfq_r.t lasted several hours-, _ 7 would they causeyou 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 roomp . 45

SUBJECT N0 . LA)O DATE t~~S 9 C o E CORD . 0 3 H ~H ; ~ a a H W O W 7 ¢ SCORING z m H m ,H x a= H H H H H H W =, U 1=-NONE 20=MODERATE E" 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 THROA T (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 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 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 , ; H z Z w 0 3 EH a

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• W x ~- . x x v~ w ~n o w CO 10=MILD LO=IftCAP . 3 w 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/ CONGESTIO N

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, cause you to : - (Refer to A-f

f 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 perfor m 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

- 

### ' . 1 r ._ / -t 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 T H ROAT I ( I (or HOARSENESS )
SHORTNESS OF BREATH NASAL DISCHARGE / CONGESTION , WHEEZING CHEST TIGHTNESS / RESTRICTION
FATIGUE HEADACHE ? ( I FRONTAL : NO YES I I
EYE 7L IRRITATION OTHER SYMPTOMS I I I (LIST) ' I. f symptoms & discomfort lasted seve r al hours, would they cause you to : (Refer to A-f

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 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
. 

# • .~n ~ ~" %, c ~ SUBJECT Na •__---- > DATE EC 0 ND - H w o w w x a z m w '~ H ,~ 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 c n 

### zo w 10= 

### 1f TLD aO=INCAP, w?` X w x w x w Q ~ 3 w c~ w cc w rs w ~ ✓ ;a 

### COUG H SPUTUM SUBSTERNAL SORENES S OR AWARENESS SORE THROA T ( or HOARSENESS) 1 ~
SHORTNESS OF BREAT H NASAL DISCfi_~.RGEJ CONGESTION ~` . LL Z-) WHEEZING CHEST TIGHTNESS / RESTRICTIO N
FATIGUE
HEADACHE FRONTAL : NO YES i EYE IRRITATION r 

### ~ 1 OTHER SYMPTOM S ?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 UBJ E CT NO . DATE_

~I~~~~ o w U F r c~ ~ z z COND
. a' a 0 3 E 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 co Eo w 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
N FATIGU

E HEADACHE / ~ 1 I FRONTAL : NO YES ~ r J I r(

EYE IRRITATION I / ~ )• I ` ~ OTHER SYMPTOMS (LIST) ?f symptoms & discomfor t lasted several hours, ~) j would they cause you to : 

### (Refer to A- H

- A . Decrease optional or recreational activity List B . Take additional medication , C . Be unable to perform the maximum amount of work that you could normally perform D . Turn this workload level 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=MODERAT E 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 f ( I ( I I l (or HOARSENESS)
SHORTNESS OF BREAT H 

### NASAL DISCHARGE/ L3 J I CONGESTIO N


### WHEEZIN G CHEST TIGHTNESS / RESTRICTION 

# ,/D

FATIGUE I ( ~ ~ I ~i ~ ~ !
HEADACH E FRONTAL : NO YE S
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 k load 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

- your physicia n G . Vlsi - 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 t e 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 x x w x w x W a rr o 3 w rt w ~ w rr W X a


### COUGH I J 5

SPUTUM SUBSTERNAL SORENES S OR AWARENESS ~ I ~ f J SORE THROAT I / ( I I ! (or HOARSENESS )

SHORTNESS OF BREATH
CONGESTIO N NASAL DISCHARG E /

WHEEZING / l I CHEST TIGHTNESS / 

### RESTRICTION r ~ l (

FATIGU E
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 U C7 2 

### . H z z w COND . ~ H H H w a o 3 c ~ 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 OR AWARENESS I I I I - ` 1 SORE THROAT i 1 I I ~ ~ I / (or HOARSENESS)

SHORTNESS OF BREATH NASAL D :SCHARGE/ CONGESTIO

N WHEEZIN

G CHEST TIGHTNESS / RESTRICTIO

N FATIGU E
HEADACHE FRONTAL : NO YES l 1 ( f I (( ( 

# ~ ~ I I EYE IRRITATIO N 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 roomGr.OUP

SrJ1SJECT NO .

17 1 DATE - ~ r ;~ x a w

+ I H H z z COND . 0 3 F a a H w o w w w ~ H a ¢ SCORING a ~ z m cn H cn H x ¢ ~ CL ~ H H H H H H W U 

### 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 W U E-H ~7 C7 z ~ ~ z 2 W 

### COND . H W 0 W W W r-+ H `a a Q i 

### SCORING a ~ z C° ~ F- ' cn H x ¢ Qr = h+ F-, .--, U 1=NONE 20=MODERATE E' w 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 AWARTERNA LENES S SORE THROA T ( or HOARSENESS) I I f ~ I (

SHORTNESS OF BREAT H NASAL DISCHARGE / CONGESTION %

F~ .t 1 ~ (~ / ~ I 

### WHEEZING 

# I ~ ' I CHEST TIGHTNESS / 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

: 

# -.__ SUBJECT td0 . OO . DATE w E- 4 H C 7 C7 z z 

### ~ H H z z w w 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 H jJARS~F~~ /0 ?-& 2 .0 ZD ,za Zlj ZO
SHORTNESS OF BREATH lv (0 ( D ld (0 /0 /0 NASAL DISCHARGE/ ) D .2-0 ,~? 6 za zo 20 ?D 2e 26 2a CONGESTION 2 2 ~ D
WHEEZING / ~ ~ /Q /D ~LO 2 b Z 0 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
0 OTHER

SYMPTOMS 20 f t ~ Z ~ ~ I 1 ~ ~ j (LIST) 5, V kEd1Ak 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 r o c 10=MILD 4 O=INCAP . 3,-~ w x w cXa °-~ c
COUGH -26

SPUTUM ,2-0 ~J J 2D Z~ 2~ 2L 2 o 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 L 0
WHEEZING 13 w .U i 2c~ sc CHEST TIGHTNESS/ ~ RESTRICTION ~ ~ ~ (b Jd l~~ 1 I J
1 ~ 1 ~ ' / ( I l I FATIGUE /0 

### HEADACH E FRONTAL : NO YES I ~y I~J EYE 1 D /v /U 10 V to / J

. . _TRR T

~ : mATION OTHER SYMPTOMS 2 4 (LIST) gv

f z 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 ~ ~ a ~ cc c~ r-, ~ yC ¢ SCORING r 

### 1=NONE 20=MODERAT E S=T,R ACE 30=SEVERE w c : ~ ~ n w E-4 w n o w 10= 4 ILD 4 O=IiVCAP . w x r-, x w x a3 x s w x w x w c = a COUGH 

## L 0 Jo
SPUTUM LO Iv ri d '2 C -2 Zb D SUBSTERNAL SORE NES 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
FATIGU E 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 for m 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 w E, ~+ U U z z 

### I a COND
. 

### 0 a H w o w w w H H a a a 

### SCORING a a z m m - m ~+ x ¢ .- - Or = N H H H r r W U 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 Z 0 w SUBSTERNAL SORENESS ~ l I I I ~ ~ OR AWARENES S 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 L o
WHEEZING lv 5 5 f~ 5 ~ c7 

### J 49F / a /



### 0

- 

### >> d' CHEST TIGHTNESS/ t ~ ) 1 RESTRICTION FATIGUE (
HEADACHE 

### FRONTAL : NO YE
S EYE IRRITATIO

N OTHER SY MPTOM S

SN£~ (LIST ) :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 A tio n C . Be unable to aerform the maximum amount of work that you could normally perform 

### D . Turn this -workload 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 NO . 1~ • ~" w DATE o w c~ ~ ~ . H c~ c~ z z ~ H z z w w COND . ~ H w a a

` o a ~ a a a w w w -+ - a ¢ a 0 

### 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 a 3 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 

### O

# R 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 ( ( ( f ~ ~ 1 ~ ' ~ ' FATIGU E
HEADACHE l i 1 1\ ( I ~ ! FRONTAL : NO YE S


### 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
W U `~ 

### 0 DATE E+ H U 7 Z z ~ H H Z 'Z , ;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 a a 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 JOP ( d l v [O 1a
SHORTNESS OF BREATH / 0 S L o 2,0 Z v Zd 2-0 Zo o Zo 2 0 NASAL DISCHARGE/ zJ zD ZG 2o 2-0 ~p 20 z0 CONGESTION 2d ~ I Zo
WHEEZING 20 Z 0 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 YE S


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

### OTHER SYMPTOM S (LI ST) SNE~yI.~/6 ~i if symptoms & dzs-comfor t 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 ,jerfor m 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 ; .a a a H W O W W W H - 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 M F v `-) `' ~ C ~G o (Z E+ E+ rz E• z r G 5=T~RACE 30=SEVERE PL; w m cn o w cc



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

### 0-C) 2c, WHEEZING 70 (J lP 10 t o
CHEST TIGETNESS/ f RESTRICTIO N

FATIGUE I 

### HEADACHE J I r 1 I FRONTAL : NO YE
S EYE IRRITATIO

N OTHER SYMPTOM S 

### (LIST) ID 16 =f symptoms & dis- comfor 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 . 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 w w U C7 E• H c~ c~ z z H H z z w =- ~ 

### COND . H H H H w a a o a 

### E~ a a a H W 0 W W W H H , . 7 ¢ ¢ 

### SCORING co x ¢ _ = a~ H H H H H H w ~J ~ 1=NONE 20=MODERATE co c SC U r t~ E cCG Ez ~ c 4 ¢ 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 A 0 /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
I HEADACH

E 

### FRONTAL : NO YES
EYE IRRITATION OTHER SYMPTOMS ✓ 2 0 (LIST) ~

v 1-f symptoms & dzs-comfor t 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) - ~ '- x a~ r H r r~ w - c ; 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 

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

X DATE c F _ C = COND . W H C7 C C E ~ •- ; w W t-, H - .7 ¢ ¢ 

### SCORING , 

### 27 Cn M H Cl) 

### H x

= 

### a C 1=NONE 

### 20=MODERATE ~ o E~ c~ U ~ 

### v " CIZ 

### 5=TRACE 

### 30=SEVERE w c . 

### 0 ~ w El 

### c 

### co U- 1 10=MILD 40=INCAP . W " w x ;4 x =a a c o 3~ ra rz w cc 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

WHEEZING CHEST

TIGHTNESS / 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 ^, z COND
. 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 U1 c~a C X E X C

~ E

cn w C

n co 10=MILD 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 " l J

~

, 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 20=MODERATE CO ~ c 5=TRACE 30=SEVERE _ ~ ~ w ~ C) ~ ~ co C C 

### 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)

SHORT NESS OF BREAT H NASAL DISCHARGE / 

### CONGESTIO
N W HEEZIN G CHEST TIGHTNESS/ RESTRICTION
~
FATIGUE ' ~~ l~ ~ ~/ ` • ~ ~ ~ ~ 17) HEADACHE 

### YE S FRONTAL : NO v/

. :J '
7-YE IRRITATION OTHER SYMPTOM S (LIST) ~ 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 E VERE c~ c c c ; C n c4 cn w M c ~=: cn 10=MILD liO=INCAP . x ca a cc c~
COUG H



### 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 l J


### 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 YE S
7 YE IRRITATIO N OTHER SYMPTOMS I I( ( ~ ~ ` 1 " (rTST~ 1 I I symptoms & discomfort 

# V1 AI1 

### ~ ted several hours /~~ 

### ~ Y1^ ,'' \V11 

### ~ \ I\ ~C+ I • ~ 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 cn x < 1= :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 c o 3 L7 C-+ Cr L cL L CC = CL p ., C c=

f ~ n 

### COUGH

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 COND . o _ F C = F w E- =

O C G Cz : C 

### SCORING a = Z cn cn x E - - 1=NONE 20='4ODERATE ~ 1 . p _ C U C 5=TRACE 30=SEVERE ~ C__- co Cr: ~ ~ w M ~ 10= MILD L O=INCAP . ~'' x H x w x w x w C c ~i- 

### ~ w rr w ~ = rr w c~ ~ a . ~ . _ 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~ )
WHEEZING 

# 1 / CHEST TIGHTNESS / RESTRICTION ~ ~ I ! ✓ ~

.~ FATIGU E 

### HEADACHE / 

# i ~ ~ O FRONTAL : N0 ./ YE S

EYE IRRITATION 

# l
OTHER SY 

### M PTOM S (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:: O H 

### 10='~IILD 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



### ~ 24 T N0 6 DATE i r E" ~" U U z z COND . . 0 3 ~- . ,~ H a z w ~ w a
~- . w a w w w
-, E, a ¢ ¢ x rt z SCORING a = r . F, M M 1~i 1~- w ^¢ V C 1=N0NE 20=MODERATE M E-' ~ r i SFT~ACE 30=SEVERE w Fo- . ~ w co ~ w co E 0 Cl: 10=MILD 40=IBCAP . 3 W X 04 W a 0 . a a COUG H
SPUTUM I I 1 SUBSTERNAL SORENESS E OR AWARENESS SORE THROAT (or HOARSENESS )
SHORTNESS OF BREATH I ~ I NASAL DISCHARGE/ rn / ~ CONGESTION !~V C

# 0o /

# o O
WHEEZIN G CHEST TIGHTNESS/ RESTRICTION
FATIGUE I
HEADACH E 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 :J P SUBJECT NO . DATE E+ U o x = COND . 0 3 ~+ ~, E a a ~+w o w w w » . ,~ a _ ~ SCORING `o a Z `n M X a x W= ~-r r i H r- ~ rr W - U L l=NONE 20=MODERATE Y o E' Q E., E E+ z e W E-4 cr SFT,RACE 30=SEVERE 0 co w co W co 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
HEADACH E FRONTAL : NO YES
EYE IRRITATION I OTHER SYMPTOM S (LIST) I Ef symptoms &

di s

-comfq-r.t I 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 E 

### H H U o z H H Z :Z (~ ] COND . , a H H H H w o a F a a H w o w w w H H ~ .] - ¢ 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 to V NASAL DISCHARGE/ ~ ~ ~ /fl ro I /,~ J ~ M /)o CONGESTIO N

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 y1 ou to : ~ (Refer to A-H - 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 3 CAP . W x '-' X w x w >e w n . a a w cc aa rs r w x t,~ - ra ~ a COUGH

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-f 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 cou L 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 ~- + ~ . ~ . a O 3 `- 

### H w o w w w H ,~, a a SCORING a ~ z °'' W 1=-HONE 20=MODERATE M F' 0 v c~ ~ 5 jxT,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 COUGH SPUTUM SUBSTERNAL SORENES S OR AWARENESS SORE THROAT ~ I ~ f f

. (or HOARSENESS) IJ IJ SHORTNESS OF BREAT H 

### NASAL DISCHARGE/ /~ ~J ~~ ~ f^ J r 1 0 CONGESTIO N
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 3r cause you to : I(Refer to AH A . Decrease optional or recreationa1 i 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 E" H ~ z z ~ z z w COND . 0 3 ' H w a H w 0 w w w H H ,a] -¢ 4 SCORING z 

### M M H H >e a s a~ H H H H H H w - v c.~ 1= 

### NONE 

### 20=MODERATE M SC O Z (L E ~ CC E-GL E 2 U [ .~ 5PT,R 4 CE 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-

~ COUG H
SPUTUM • ~ ( I SUBSTERNAL SORENESS I OR AWARENES

S SORE THROAT (or HOARSENESS )


### SHORTNESS OF BREATH ~ O 1 NASAL DISCHARGE / CONGESTION f~

WHEEZING CHEST TIGHTNESS/ RESTRICTION
FATIGU E
HEADACHE FRONTAL : NO YES I f
EYEIRRITATIO N OTHER SYMPTOMS I UN~~, I I I C :~~,t . ~yE~ 1 I( (LIST) -4 E ) If symptoms & dis

-comfor .t Ilasted several hours, vould they cause you to : (Refer to A-a) L A . Decrease optional or recreational activity List T
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, 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~{ E M C C z = DATE ~~ a w

COND
. O 3 ~••~ w .3 F-1 w o w w w M, HE, , SCORING M m M x a z M x1=ftONE 20=MODERATE a ~ E-' E~ 5''- T ,R4 CE 30=SEVERE w a~. ~ W m w E co w

e 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•comto r-.t lasted several hours, W would they cause you to : (Refer to A- $ A . Decrease optional or recreati nal activity List 1 I 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 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 w F H w ~ COND . 0 3 z W w H 

### ~, w o w F SCORING a z M H rwn ,~ ~ H X a ~ 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 z H H Z' y [ ~ 

### CO ND . H w .~ C 3 E, 

### H w o w w w H H a a SCORING a~ z `n m "" m H x ¢ (L = H N M H N H W 5 . U 

### 1=-NONE 20=MODERATE 00 Se o s a E E• cc E z E ., • 5"=T FACE 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 SPUTUM SUBSTERNAL SORENES S 

### OR AWARENESS SORE THROAT (or HOARSENESS)
SHORTNESS OF BREATH NASAL DISCHARGE/ CONGESTION
WHEEZING CHEST TIGHTNESS/ RESTRICTIO
N FATIGU

E
HEADACHE i \ ~ ~ \ r ~~I FRONTAL : NO YES ( I l i ( EYE IRRITATION i OTHER SYMPTOM S (LIST) 1 I ' - - I f 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 z z w ~? 

### t~ ~ M W a / 0 3 r' `~ f, H a 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= 

### MODERATE 

### M E' v E Se o s rt E+ rt F+ a EH E+ 

### 5*T,RACE 30=SEVERE w M . C w m w m w M o w m ~ 10=M nD 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.

S ~ ~/ ~ I I O COUGH /~ SPUTUM 1 v SUBSTERNAL SORENESS I r ~ < OR AWARENES S SORE THROAT I ( ( ` j (or HOARSENESS) ~ l 1 ✓ I ~ ( SHORTNESS OF BREATH ~ l I I 1 I ~ NASAL 

### DI S COAGESTIOAHARGE/ ~ ~ ~ ~ O I O ~ ~ ~} /

# oF i

WHEEZING ' ~ I ~ t I I I CHEST TIGHTNESS/ < RESTRICTIO N

FATIGUE I I i ~ 1 /
HEADACH E FRONTAL : NO YES S 

# I ~ EYE 

### IRRITATIO N 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 : x Z E- H C7 0 

### ~- o s F H w o w w w H H a a ¢ x x z m m H m H x a x = S C O~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 ° W M 

### a x 0

. 10=MI LD 40=INCAP . w X '' x w w w o 3 w x w rz w cc w x o a a 

# 2 0 

# l0 ~ id COUGH


### SPUTUM I I V ~D ✓ Ir~,~~ ~v 1 U l~ `~ SIIBSTERIIAL SORENES S 

### OR AWARENESS l 

# J ` > > J SORE THROA T (or HOARSENESS) . ~, SHORTNESS Q V RASAL DISCH

### AR

### ,(~ ;

# 0,20 2-0 ~ O - lJ CONGESTION ~ ( . WHEEZING CHEST TIGHTNESS / RESTRICTION Z~ /f~

FATIGUE
HEADACHE r FRONTAL : NO YES 

### 1 1 

# U 1 IJ I
EYE IRRITATIO N 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 perfor m 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
. C z E, H c~ o z = z w a ~ ~ ~ E a a 02f D
. 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 E o 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 THROA T (or HOARSENESS)

SHORTNESS OF BREAT H 

### NASAL DISCHARGE/ I CONGESTION J 

# 0 r10

~ 

# -~

-

# o
WHEEZING ( I ~ /~ CHEST TIGHTNESS / RESTRICTION ~ I~ CI I O ~ ~
FATIGUE HEADACHE ~ (J 

### FRONTAL : NOYES , 

### >- I 

# ID ,
EYE IRRITATION OTHER SYMPTOM S (LIST) 1 l 1 Lf symptoms & dis

-comf(P r. 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 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 ~~~ ~ ~'\ o w ~ c E-4 H U ~ 2 z 

## `l7r' H H 

### z z w OgD . ('Y H H H H W a

. 0 3 E -4 a a H w o w w w H H a 

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

### 1=-N

### ONE 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 x $-4 x x W x w a a o W cc w z W ,z w cc = a a. COUG H
SPUTUM [O to 10'o Iv jV tO L~ SUBSTERNAL SORENESS ( OR AWARENES S 

### SORE THROA T (or HOARSENESS )

SHORTNESS OF BREATH J ~ ~ ( l l r SASAL DISCHARGE/ CONGESTION

WHEEZING 

### CHEST TIGHTNESS/ JO T~ ( ~ l 

### ~ I 

### /, 0 RESTRICTION 

# 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 the y cause you to : (Refer to A-H 

# t l-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

T ~ C ~ 

# 3 ~~'~ o w E v 

### H v c~ z z H H z z W ~ 0 BD . Q 3 ,~ H H [r] a E H W O W W W H H a ¢ ¢ a Z tA CA M ?C SCORING = H r, H H H W ¢ V U 1 -N ONE 20=MODERATE M E U 0 0 E 5xT~ACE 30=SEVERE w c 0 .- o w m w ~ w to a w M E10=MILD 4 0=I14CAP . x X W X W X W a a W cc W to W x W z ~ a G,, a . COUGH ~ ) I / 1 J SPUTUM {~• ~ ~ ~ ~ ~ + ~ `C SiJBSTERBAL SORENESS 

### l ~ OR AWARENESS ' '' I I I /~ S SORE THROA T (or HOARSENESS ) SHORTNESS

OF BREAT H NASAL DISCHARGE/ CONGESTIO N
WHEEZING CHEST 

### TIGHTNESS / RESTRICTION 

# 1 1
FATIGUE I , / f
HEADACH E FRONTAL : NOV YES
EYE IRRITATIO N OTHER SYMPTOMS I ( ( Q J (LIST ) I f symptoms & d=s-comfQr 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 ! 

## fto . CT [-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=N ONE 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/ ~ - f ) - CONGESTIO N

WHEEZING / l J ~ O ~ O C~ ~G I ' I CHEST TIGHTNESS / RESTRICTION
FATIGUE 

# ) 1 1 I ~ / HEADACHE FRONTAL : NO /YES

_
y 

# ~ ~ ~ ~ _I I EYE IRRITATION I I ~ OTHER SYMPTOMS (LIST) I I If symptoms & dts

- comSq-rt J \ , lasted several hours- , would they cause you to : (Refer to A-E r 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• ulit i

~' . 

# -5/7 Ju ,t .t o W E' H z z w W I ,
... , H H H w a a 0~• 0 3 E 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 CA E U U U E-~ f'L 1=i~10NE 20=MODERATE o z a E ., E• X E• z E~ pA C E 30=SEVERE W cc co co o W m H 5=T♦ `, 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 

## -, C COUGH 

# 2-6 1 ))

SP

# U TUM 

### C7
SUBSTERNAL 0 

### ~ l
SORE THROAT 10 

### ~ I l ~ ~ • I / ~ / (or HOARSENESS )
SHORTNESS OF BREATH NASAL DISCHARGE/ CONGESTION

WHEEZIN G CHEST TIGHTNESS/ i ~ ` • ~ ~ RESTRICTIO N
FATIGUE 

# 3 /



# ~ HEADACHE ~/ FRONTAL : NO /~ YES_ 

# ~>> i ~ ~ I EYE IRRITATIO N 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 perfor m 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 72 4 < . .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 77 4 (• •~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 . 6 42 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 P RE 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• • .N1 • .2 3 .744 3 .4 01 l .41i 4 .437 i .13{ 4 .14 0 I . . 7 .IN 3 .2N 3 .1N • .147 • .)F1 4 .1i . • .13t • ./ 1 .4N 1 .iN 2 .3N 4 . 9 3N • .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 5 { .41f 3 .4N • .13f i ./21 • .3 i .Ni 7 .3N 3 .3ii • .472 • .N2 • .433 • ./33 /, . 3 .43i .496 3 .43f • .H1 4 .1 6 3 4 .462 • .134 • .4 ~ .7N 2 .1 0 1 2 .4 6 1 4 .41 111 4 .341 / .3 00 0 .317

C-2 2 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 Se o F+ rz F+ rz E-4 z E-, Ec~ 5 ;~T~RACE 30=SEVERE w ra ; ~ w co w co w ca 0 w m H 10=MILD hO=INCAP
. PQ X x w x w x w a cc o 0 3 w cc w a w ~ w x ~ a a a ca COUGH

SPUTUM SUBSTERNAL SORENESS OR AWARENES S SORE THROAT (or HOARSENESS)

SHORTNESS OF BREATH NASAL DISCHARGE / CONGESTION 1 /

WHEEZIN G 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 .

~If~'-OS W W DATE a w 0 E-+ . H v U z Z ~/ H H z z w w COND . H H H H w 7 a 

### o s 'r a a H W o W W W H H .-a a Q SCORING
. a z z m co H co H x < LL H H H H H H W U 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 x w X w a .~ o o a W w c~ w e w rs a a o . co a
COUGH

SPUTUM SUBSTERNAL SORENESS OR AWARENES S SORE THROAT ( ( rl ~ ( I ` 1 ~ I (or- HOARSENESS) I
SHORTNESS OF BREATH , I ' I I ` ~ / ~ NASAL DISCHARGE / CONGESTION I ( (

WHEEZING CHEST TIGHTNESS/ RESTRICTION
FATIGUE ~ ~ ( I ( I1 + ~
HEADACH E FRONTAL : NO YE S
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 d ner°cr

m D . Turn this workload level down(disregard fatigue ) E . Be unable to perform your usual work* activity or level o f (* occupation, schoolaor' --, c__tical househo 'id duties ) 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 OU P SUBJECT NO . DATE J ' l w E W v C .7 H U U ~ Z COND
. ~ 0 3 H ~+ H H w ,~ a h a ,a a H w o w w w H H 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 c o 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 YE S

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~~ .mGROUP ' ~ '` ~ ~ 1 i~ ~ ~ ,1~ ✓ ' ~ ~

SUBJECT NO
. {'/ w DATE I ~~O~ o w c~ z Er H U U z w H H z z w a COND . H H H H W o a t• a , .a a H w o w w w H H a ¢ a SCORING
. z cn u~ H rn H x _¢ ~ x CL H H H H N H W U U 1=NONE 20=MODERATE E' " 0 U ° Se o E

- c E~ E~ z F Ea c c w v~ m H 5*T>RACE 30=SEVERE w a: 0 w cn w co w cn 0 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 S SORE THROA

T (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 

# ~ ► I ~ I ~ 1 i (LIST ) 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 ti me 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 O w ~ U DATE E~ H U U Z Z z z w a COND

. V/~ ~ H H H H w n ] 

### o s E• a a a F-1 w o w w w H H 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 OTHE R (LIST) SYMPTOM S ?P symptoms & discomfor t lasted several hours, /y~+1 - --- - -- - would the y cause y ou 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 perfor m D . Turn is work -"cad level down(disregard `a

- . ;gue ) E . Be unable to perform your usual v ork* activity or level of roductivity c~ :es) occupation, schoolwork, critical househol d F . Stay at home sic k (lose sic k time from uors)v G . V_s-it your rnysicia n R . Visi ., an _=e--Fency room

### p . 94 -A

GROU P SUBJECT NO . DATE o H c~ ~ z W H H z z w a COND . ~ H H H H w a a o F a a H w o w w w H H 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 a ctj
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 TIGHT N ESS/ / r t RESTRICTIO N

FATIGUE
HEADAGHE FRONTAL : v0 Y E S i

EYE IRRITATION / ' / / r ~ OTHER SY M PTOM S (LIST) ?f symptoms & discomfor t 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 fZ H ~ Z W w COND . _~ ~H-+ H H w ,,~ a o s a ~ a

0 W E-4 H W W w H H SCORING pa j z H H H H `n H y~ a U U 1=NONE 20=MODERATE ~ F_' U O 5=~RACE 30=SEVERE c oi W EH ~ ~ o w 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 YE S

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 emergency room

### p . 96 a

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