-

. . . . - -- :

; : -= - - _ _ ~ - - - - - - -- ---- -~~'~--

SU3JECT NO . LOc,7a-`

4kk DATE 7 lG e!5' o

H H v U

COND . J

c~ ~, F, ~, c~ z

0 3 ~"~ w a a

'-' Z z c +

►-+ w o w c~ w ~, E-.., a

SCORING .13z

Cl) H ~n H m

1=NONE 20=MODERATE ~ E' 0 ~

C

5=TRACE 30=SEVERE A; C W ~ ~ w

ca

z F, E-, ~

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

3 w c~ w rt w c= w a ~ p, a o ~

COUGH

J J

SPUTUM l S/~ 5-5 5 5

SUBSTERNAL SORENES S

OR AWARENESS

SORE THROAT

(or HOARSENESS)

1/0

s S ~ ~ I 1 ~

SHORTNESS OF BREATH S

1 c

NASAL DISCHARGE/ '

CONGESTION

WHEEZING

CHEST TIGHTNESS/

RESTRICTION

"7 C/ J

FATIGUE -)n Ix /O J /oi l

HEADACHE J

FRONTAL : NO YES

EYE IRRITATION

OTHER SYMPTOMS

( LIST )

symptoms & discomfort

sted several hours,

uld they cause you to :

efer to A-S)

l . Decrease optional or recreational activity List

; 3 . Take additional medicatio n

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

perform

;) . Turn this workload level down(disregard fatigue )

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

occupation, schoolsrork, critical househo ld duties )

Stay at home sick(lose sick time from wor k

Visi ;, your physicia n

Visit an emergency room
SUtJECT N0 . LOC~~

DATE

11

E ,i w C CC

i

COND .

'/ ~° w o w G

; ~ E-' a ~ a

SCORING a ~ z M m ~, ~ f~, X ~' a ¢

1=NONE 20=MODERATE PH v v

5=TRACE 30=SEVERE w CC. 0 w m F+ z c' E Fa

10=MILD 40=INCAP . 3

X W a a X a-2 -2 a~.

to

F=' a p a

o 0

U

COUGH U r7 n a_b 15-ID ~-U ttj "

SPUTUM r1 110 6, ~J

I ;o

SUBSTERNAL SORENES S

OR AWARENESS

LO 1)0 0 f ~ L?

SORE THROAT

l

(or HOARSENESS) '1 1

SHORTNESS OF BREATH C') ~

ljo '901o ~ ~ ~ ~

NASAL DISCHARGE /

CONGESTION

1/0 J 1 n D t) /0 )/n

WHEEZING

6

CHEST TIGHTNESS/

RESTRICTION

20 9"0 q1n 9 1 0 S .S

FATIGUE

1 .10

n~

O' v Q`~~b o d ~~-~

HEADACHE

FRONTAL : NO YES j ` I ( /O 1(

1D r

EYE IRRITATIO N

OTHER SYMPTOMS

(LIST)

s ymptoms & discomfor t

: L sted several hours ,

i ) uld they cause you to : /}. ~

~ tefer to -A-H) n /-~ A , A . Decrease optional or recreational activity Lis t

13 . Take additional medicatio n

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

perfor m

~ D . Turn this workload level down(disregard fatigue )

~ . Be unable to perforr, your usual work * activity or level of productivity

(* occupation, scho o lwork, critical household duties )

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

1 . Visit your physicia n

H . Visit an eTe r gencv room
p' 3

SUtJECT NO

. DATE

E F' ~ z z

COND . ~ 0 3 H F+ t-+ r~, W a

+ H W o ' a a W H E a H

SCORING a ~ z ~ m H cn H y~ 4 ¢ ¢

c

1=NONE 20=MODERATE `~ E-' 0 H ~ H H H U o 0

5='! RACE 30=SEVERE w co-

~ H w ~

. 0 W ~ ~ w ~ a E F

10 =~~iILD 40=INCAP . W x ~; a W x x W x p-, ; W co

o

c~ W c~ = a p., a Cr

COUGH 120 o rwO 1 ;_'_0

SPUTUM

I l 0 O l1) n 2~ 0 /'0

SUBSTL'RNAL SORENESS y ( I

OR AWARENESS

I f > > ~ , ~ J

SORE THROAT

(or HOARSENESS) if 10 0 1101 U

l~

SHORTNESS OF BREATH

0~

n(

90

n

o IP-

~

NASAL DISCHARGE/' 1/

CONGESTION

10 5

WHEEZING

an I ~ l o /0 /0

CHEST TIGHTNESS /

RESTRICTION

I v oLY J ` c~C .20

FATIGUE

~ C ~~ ~ ~~•J ~r ~-'J ?/~

HEADACH E

FRONTAL : NO YES J

EYE IRRITATIO N

OTHER SYMPTOMS 1

(LIST )

symptoms & discomfort

sted several hours, I

: uld they cause you to : ~

efer to A-H ) 74, 14

Decrease optional or recreational activity List X". rC.I~L

3 . Take additional medicatio n

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

perform

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

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

occunation, schoolwork, critical househo ld duties )

Stay at home sick(lose sick time from

: . Visi t your physicia n

Visit an emergency room
R=

l~

Sli$JECT* NO . Cl~21

DATE 6M~ ~ 0

F, G; 0

0 z zt

3 H H H Hz z ~,COND

. a W

H L7 Q W W W M ~ a a

SCORING [

Q

C az

.. =)

Z Cl~ M H C!~ H y~ ~` _

►- Q

v(J] E~ U U H H M H H H ~ '-'0

~

~ C1=NONE 20=MODERATE

5=TRACE 30=SEVERE w a

Wx C _W M

X X

~ M W CD o F' ~

40=INCAP . 3 ~ a W a W aW X W a

W a o a a~

10=MILD P--

COUG H

SPUTUM

SUBSTERNAL SORENES S

OR AWARENESS I ~ l t I ~ ]

SORE THROA T

(or HOARSENESS)

IT 1

SHORTNESS OF BREATH

1 5

NASAL DISCHARGE /

CONGESTION ~ ~ I ~ I I r r ~

WHEEZING I I ~ ~

CHEST TIGHTNESS/ I

RESTRICTION

FATIGUE

HEADACHE

FRONTAL : NO YES

EYE IRRITATION I I I

OTHER SYMPTOMS

(LIST) _._. ----•- ' - --.___ ._. ..

& discomfor . symptoms .t

sted several hours,

uld the y cause you to :

efer to A-H). Decrease optional or recreational activity List ~j(Prtr [1~~;'~{rPrSel . Take additional medication y. _

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

perform

) . Turn this workload level down(disregard fatigue )

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

( * occupation, schoolwork, critical househo ld duties )

Stay at home sick(lose sick time from, wor'.{)v

Visit your physicia n

V'_si an emergency room
GitOUP 2"

SUBJECT

• ` ~~

NO . L4&4Fr"

DATE 0

E' - H o c5 z z

w ~ ~J

>

0 H a a H H z z w w

COND . 4

oc a z

W 0 W W W H H a

H H a

SCORING m CO CO x

p, ~ H H H H H H W ~ U ~

l=NONE 20=MODERATE 0 o ~ c> c

H F c 5=TRACE 30=SEVERE w a W ~ co x ~ o W

to Cc 10=MILD 40=INCAP . WX '' x w X w X w a a o o~

3 w a w a w x w a ~ a a, o c

COUG H

SPUTUM j v

SUBSTERNAL SORENES S

OR AWARENES S

SORE THROAT 1

, •I 1 1 -1

(or HOARSENESS )

SHORTNESS OF BREATH h 10 /

C/

~ 1/ C

NASAL DISCHARGE /

CONGESTION

WHEEZING

CHEST TIGHTNESS/ f J

RESTRICTION •) ~ j / ~ 1'~ ~ ~ , ✓ ) ~ ( ( I Jr

FATIGUE

1 v ( ) a 0 :~ C~ ~, ✓ ~) ~ ) /0

HEADACHF, /•~

FRONTAL : NO YES I ' ( I ~ ~ ~ ' 1 v j

o

EYE IRRITATION

OTHER SYMPTOMS

(LIST )

f symptoms & discomfort

asted several hours ,

ould 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 s 4 ck time from work)

G . Visit your physicia n

H . Visit an emeroency room
il out each column for how you felt th previous 24 hours . ~

MWHAT WAS THE WORST SCORF~ FOg

Z4

W YOLT:

T~ -S, ANY TIME DURING THE WEEK

-T

COUGH % ~ 1=NONE: No symptom.

SPUTUM ":i 5 5=TRACE: subject must think

'C5 / 0

SUBSTERNAL SORENESS 5

~ about symptom to

appreciate its presence .

SORE THROAT ~

~ 10=MILD: Symptom present

without thinking about it

SHORTNESS OF BREATH Gl ~ but not annoying

.

NASAL DISCHARGE I ~j I 20=MODERATE : Symptom present

WHEEZING without thinking about it

f/ and annoying.

CHEST TIGHTNESS f ~ 0 30=SEVERE : Symptom limits

FATIGUE n activity and performance.

HEADACHE 40=INCAPACITATING : Symptom

causes on-going activity

E YE IRRITATION or task to discontinue .

OTHER

JSE BACK OF SHEET IF YOU NEED MORE ROOM FOR ANSWERING THE FOLLOWING :

Jas this a GOOD, USUAL, or BAD week? If BAD please describ

e

)id your symptoms cause you to start or change your usual medication? YES NO

If YES describ e

q

ere you unable to do your usual activities because of your symptoms? YES N

• O ~-/

If YES describ e

)id your symptoms cause you to contact a doctor? YES NO

If YES, what did he

say about your problem ?

)id your symptoms cause you to visit a hospital emergency room? YES NO

If YES describ e

'OR ASTHMATICS :

id you have any asthma attacks? YES ~ NO

If yes, how many?
P. 7

iaTi

OND

E- =- ~=

. / ~ • °1~~ o ~ `' z z ;-

G a h < <

.: • -~ ~ ,

C 0 P, 7 NC CO Co H co

- P-• ~ t i H t f~ r r. _ U C

!=NONE 20 =MOD Cr E c~ c~ c~ c~ C:

5= T' RA CL 3 0= S c . ~: V :. 3 ~

C = E-+ E E z F ECO c.: m t=~ cn o CC cn r-

,

0=M! LD 4O=IVC? a CrOUG3 t S S 5T

?UmU

JB STL

M

.°.NAL

I / ~ / ~ J

SORENES S

R AWARENES S

ORE THHO"_T

or HOP_IR Sc,NESS )

aORTNE SS OF BR ET ?^ ._

~-SAL DISCHARGE/

ONGrSTIO N

= E 4zlNC

H-E

STR i C`"r0~v ~ ' C

ST T_GZ^NESS /

m 7 G U E

I D r_ C II :

E IRRITAT IO N Y '

-'H,ii SYMPTOMS

(T_IST)

Ym n toms & di sccm_or .t

,ea several hour s ,

d they cause yeu to :

_'_' to A _cT )

Decre a se optional or rec r e a tional activity List ~ Take' a'dditional medicatio n

Be unable to perform the maximum amount of work that you could nor

,

mallY

perfor m

Turn t hi s workload level Qo w n(Qi sregard fatigue )

Be unable to -c er : orm your usual uorkl activity or level of rroductivi t?

(l occ oa ioc, schoolwork, critical househo lc c.uti °s )

Star
p8

~~

D J

SUBJECT NO

2j- ) 2- . DATE

E H

w H c7 r~ z z

COND .

CD '-i

(D F

SCORING a r~ z cn cn

H H H H

H

C-)

l=

5=TRACE

:dONE 20=MODERATE

~ O tz E tz E !r E z

GO F v c~ c v

~ 30=SEVE : E c.

. c w cn w cn w u~

10= M

1LD o w cr = 40= 7 NCAP .

>

~ w cz w cz w cr w oc ` H X F x w x w a a o

^ a, ~, o c

COUGH

SPUTU

M SUBSTERNAL SOREN E SS (- /

OR AWARENES

S SORE THROA

or HOARSENESS T ( ~~)

SHORT-NESS OF BREATH ~ ~ ~ r0 l^ ~ I 6 a~

N^

CONGFS'`'_OiV ~ ) )

.SA_ D1SCfi _?GF %

WHEEZIN G

R =S^ R =cT l oN

F~T_GUF

HEADACHE

FRONTAL : NO YES ~ / ) 1 /

EYE ! R R

; "' A 7=c N

OTHER S ImpmOMS

(LIST )

: s Ym -i to m s & discomfor

, t -asted several hours

:Cll1Q t ;eV cause VOll t0 :

; e :e_' tOV A- FI )

A . Decrease optional or recre~tior.al acti\vity Lis `

B . Take additional medicatio n

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

per `or-n

0 . Turn t h is workload level dow-n(disreyard fatigue )

to oe_'c_ . . vour usual «o - _ . act, -r or c_ -

sc :-oclwcrI~ cr_ .,ica_ : ouse^o 1 _

s_ _ e s-.--{ :e W 0 _-.,
~ J E, C'= :vu L`t 7a,

p.9

'ATE

OND

-

.

fo

E-_ ~% L z z

CORING Co tn t-;

r4

GO

F' ~ ¢

!=NONE 20=•"_~?ODE

a ~-! ►- t; ~-+ ~- ~ ,- x ` I1 -"'E cr, ta 0

~

C

5=TRACE 30=SEVERE E E`

U

cn P-. cn ::~] m rz-z- U, CF =

o

0=MILD 40=7VCA?

-

c

y c= ~ c ~ c~ c

: x H k X c >< w o

c P0UG

7BSTERNAL

H ?UTUM

SORENES S

l ` t

3 AWARENES

TS DRE THROA

HOARSENESS

(;--7

=ORTNESS OF BRu'_^ F

!SAL DISCH4RCE/

>NGE.STIO N

= uZIUC

/Oit

.S

E ST TIG

TRTC TTO!

'-;'T'YESS/ G

V

T C-JE I ~ S r, -6

`_DP_CuE

ONTAL : NO YS

I/ )

I / ~

~ IRRITATIO N

HER SYMPTOM S

LIST )

( r~

IL

-m-itoms & disccr=or ~

d several hours , i( (

they cause you to :

r to .4-3 )

Decrease optional or recreational activit -r L'st

Take additional medicatio n

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

perfor m

Turn t h is workload level down(disregard fatigue )

Be unable to Derform your usual work` activity or level of DroauctivitY

( OCC1D2t10n, schoolwork, 1 -critical id duties )

Stay at no -~ _ s_` k( l o S e s-' C7-

V,-' - ~ "Cl: "

V4-

5_ ?: - 7: C'r _ :7~1
P,

10

'`= 'T

0 U D

L ~

C O° l YC ' ~~.Cn H cc ~ y~ ,

=

!=NONE 20 =MOD r

- .. . ~_m:-~ ~ C )

- ~0 1 C 5-'? 3 0 E =S EVr-z ~ E• U C .3 E ca c: M Cri 0-'~-- LD 4 0=! N C A-D .

P-:X `r' Cr

0., C C. n

~ ~ -• '~-, ~,., C'_

O U Ga 17 1

? U T-UM I S ~ l ~ ~ ~ 1 ) 1

TB STE°N4L SO RE NES S

A.Y aRL.'i`T!',S S

) Rr. `iE R C A`f'

i ) J

~r HOARSENESS) ~

I's 5 I I / I

:ORTI-ITESS OF

x'D

Sr?L

Y c E STTa

D I S CH

Y

A _RCE/ 1J

~ . Z Z _ 1G

EST T! Ga^N ES .;/ ~ ~ .

ST DIC 7

T0 Iy

1 ~ = 7G J 7

_

\

- f) \ I's kr l6

j NTCL .NO Y~

~

S

/ I l C

IRRIT-'I T !O N

?E ;? S Y AP TO ~,tS

-ST)

--,~, i.o47s & di sCO M 0 r .t ~ ~ ~ ~ ►

several hours , /

the ,r cause you to `

tJy ?-r~ )

Dec : ease optional or recr ea tlona i Zc t 1Y1 t:t Li st

Ta k e additional medicatio n

B e unable to De'_' :o :m the IIz :c?IIuIIl amount oi G'Jr!{ that Votl could ncrmal!Y

De : ior ..-1

Turn t h i s uor!load levei dou-n( di s regard iatijue)

B O D*CQllC~i'f'_tf e unable t o Je_' :o~~ Volli- usual work ac t i'fitf or level

(` oc c uoa ti- on, ~ choc L ,:c r c- : t ical house^c 1c cu t i_s)

S t a a t home - ~o~ ; o r )V

S _ ~ .~u_ . • r~ _~ __ . .

r-=- - -•- ---- -- _ _,-
j C ~ \ p. 11

,mJ

. . . z

09D . e~! ~ N' F Z

L ,r--•- :=?

F"

COR_NG r-~ Gc x -

1= N 0 NE 2 0 =:1 O D E R_^-_':': a% c.~,~ C )

5="-RACE 30=ScvEsL ° ~ r:~: Ef!1 G ' : Co C

0='47 LD ZO=Y NC?P . x x cr=1 =: x e= x c: ~ ~ ~

OUGa !/~ , 1

PUTUM

73ST E°NAL SORENESS

~ i -

r 1

5 5 I r ~

aWa RE.IRSS

L

~ _

)RE TRRO-T

'I I

)r fi0 AL 3Ss;NiSS )

1-7

ORTNESS OM BP.~^_= E

:S :?il DISCHARGE/ ~

) UG E S '_ T " O 'N

E, ~~ G /C~a~~~~ 5 > 11 1

, ~ - -RST TIGHTNESS /

:S'"D=CTIOy ~ /(~ ~l~ )C~ ~~ /~ ~!•~j -l

~ ~ U E

OYT^L NO YES \ ~~ /

E IRRIT_^-.m TON ) ) I ) ~ ~ ~ I ~ '

HER SYXP `^Otif S

(L ST )

m i to m s & discor_cr.t

:d s etreral hours ,

t`ney cause you to : ~ ~ (C •' C .

Decrease optional or rec .e a tibna l activit -r \ List

Take additional me d icatio n

Be unable to pe r =orm the maximum amount of work t h at you could normallY

perform

Turn this c:or!~: loac le v el do~: n( di sre g ard fatigue )

Be unable to De :' :o'"_^. . `rour usil --! 'w ortCLL act--'-r4-t-;- or l e`re L of DrJQucLi'r it T

i oc c uD2 -' ion SC^Oo , ~si hou i::C~r Z l ~- ._ .c 1c cu~ies )

St`_ a~ home s_ C ,( ! cse s c time f-c m

v : _ .~. " O : r

•~ - = _ . _ ._ _ _. _ _ _ ._ _ " ~ "
p.1 2

A l'fE

// /~ ^~ G` - / ~ f~' • \ ~ , E-.

0 ND

c. z z

c - ~ -- -

L

.O a r_yG co cn co

!=NONE 20=MODERATE CC Er- c; C.; C.) ~ - r ~ z - -

DA C E 30=SEVERE: L-: cl_; C: C ECr] C vl C u]

E- ~ Z U c. . c- ~

=+if i Tt D ~10=iJ.`~C~ C- }C O cc G^. r

C C

C'

.lR'(lm

~ STERNAL

a?Y a~ ENES

SO

S

REN E SS ~

_

-'T-.

M iR 0A a T

opRS ENLSS )

- Rm NESJ OM Ba L~_~E `J

_ : L DISCHARGE /

: :

,:IE S T70 rr

- E ul N G 1 5 ~ ol

- 77- T T 7 GL"VESS /

-,RTC mrOi,;

-_~J~ `3~ ~6 ~ - ~ / ~ ►

:-TzL . NO YLS~

i

IRRITATIO N

=~3 S C'~p^OMS

t

-~ST ,

several hours,

-- ae ;r cause you t o

_: ecrease ootional or recreation -al activi t•r List I~\

ake additional medicatio n

e unable to ner=ory the maximum amount or work that you could nor=allY

=erior ~

_urn this c:orkload level dovn(disre?arQ i=t>>u e )

unable to ner=or: your usu~1 Vorac ti I or 1e re_ o : ~ro~uc

occuDatior., sc :001 ,w o ;-c_ _ticai hcus~ ._ cu es

:;a,,, a nc~_ s__ . (iose :-Cm ,
p. 13

A M V

0 ND .

F

C oR 1 NG ~Po2~~ Co

A.• •~ F= F-i 1--~ F-i i-! F-i C-: ~-- U L:

-:=NONE 20= :_ODER_^-_`"i ~

o F ~• F z c-

%

5=iRAC : 30=SEVERE e: r=: m c : m c=~ m o G Cr:

'_MT LDL O- -_' 1 INCP--r, xi >< Q

- c_

)UG 3

'UTUM

'BSTERNAL SORENES S

AWARENESS Illo

3E THROAT

- SOP_qSc,NESS )

D R'INESS OF BREATH

AL DISCuanGE/ J ~ ~ J

_"Gr^,STION

_ E zl NG

s ~ ~ ! l l~ ~J 6

~' T TIGHT NESS ,

=TCr0w ~

-_-GU E

C uJ

'" TAI L : NO Y E S

IRRITATION

~ 'LR SYMPTO M'S

= 7 sT ) 'q e ~k ~ -

-2 toms & disccm_o-4.

several hours,

hey cause you to :

to .4-ff)

ecrease optional or recre a tional activit-r List

ake additional medicatio n

e unable to perform the maximum amount of work that you could normallY

erform

-:urn this crorkloa d le v el down(disr e g ard 'fatigue )

e unable to perform your usual w ork` acti,ritf or le v

el of producti-%i t .r

occuDation, sc7oolaor!c, critical hcus e io id duties )

ay at home lose sick ti : e :roc ~or_c)v

~ y your ph_rs __ _a n

_s_„ a : e_ cc ~c~ i
VJ

j

A.TE

E- C

_

:

L

0 TI D . r= r~ ~ ~

C y E, i .: , •=

CO°IVG rn c:

70

t- c~

~

~tONr: =M ODER_-_ T E

cr, c ) C.) c

r

n : L, E E E- E E-- 5='LRAC : ., 3o=SEVERL CO C=: Cn rra m o Co cn

,D=MILD 40=IVC I,_° e X c; >< P. 9= o C c C= c.: C- C r

D UG H

?UTUM

_BSTiRN4L SO RE NESS

AWARENES

RE THROATS '

HOARSENESS) f ~ ~ f ! ) l ~ f ) 1

O RT'NESS OF BRS^_^_ E

aL DISCfiP_RGc

_'CEST?'OY

_EzINe

_ST T+_G3T NESS /

~R!CTIC N

cJ E

DA C 7 ~ TnL : NO Y~ S

IRRITATIO N

._~

_ ST) ) ~ I

11 S Lu?To M s / ' I J I f f 1 ~ /

=toms & di=ccr=or.t \ J ~ ~? i1

several hours ,

z aey cause you t(D : v) ~/

t o

- ;-crease ootional or recre a tion l activitv List

=ake additional medicatio n

_e unable to perform the maximum amount of wor Lc that you could normally

_erfor m

_urn this workload lev il 1 dovn( di sregard fatigue)

unable to perform your usual uork` o f producti ri t r acti-ri t y or leve l

occsoation, school w or k , critical house^o ld duties)

t ay at home s :c'ti( l ose sick time from v

: S : ~ you--
✓J

p

15

DI ,-n

O '-'i 17 . ~ I F- _ c' C z z

-t t= C C=; ~ H : ~•

3C OHINC 6( 76 2~, CO Ca GO ~-,

l=`rONE 20=MODERATE Cn

E c

C-)

5='R4CE 30=SEVERE G-;

Cn LO=MILD 4 O=INC A o . ^

.OUG H

3 PUTUM r I f ~ ~ / (

; UBSTLRNAL SORENES S

)R AWARENESS 1 ~ 1 ~ 1 I

;ORE THROAT

or HOARSENESS )

H oR TNESS OF BREAT H

AS A L DISC3 ARCL /

O N G EST-O N v ~ ~o ~" l0 5 ~o ~~ jv I a

HEEZING

:.EST TIGHTNESS/ ~ l ~ I 1 I _

ESTRICTIO N

s~~~JE ~ ~ 1 ~ I t

E ALACIIE,

RONTA L : NO YES

'L IRRIT_^-.TION

I'Hr,R SYMPTOMS

( L !sT )

ym ~_toms' & disccmror~

ea several hours ,

d they, ccause you to :

er to _4-a )

Decrease Optional or recreational activit_r List

Take additional medicatio n

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

perform

Turn this workload level down(disregard iatig-ue )

Be unable to periorm your usual work* activity or le,rel of productivity

(` occuoation, sc h oolwork, critical household duties )

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

Vi sit your nn .rsicia n

Visit an emergency room
- •- _ - , -• -' - ~_~!~ j f / p.

1

A

r ;

~

~

~OND . ~ ;~ •e_ `'~s `-`" ` `

` ~ -J _` ~-• F-., ~--

C0? E VC Crio ?"(O i

1= 1 O A 20=MODERATE v

5 = ? 3ACL 30=SEVERE Q E-,

cn Cn (D

E-

_p=M r LD 40 =1NC?_ P . x G+ x ~ r~ Collrn

[--7 Q= ° C.

, DUG3

?U"_'UlK

~ 'UBSTERNAL SORENES S

- . AWARENESS ( 1 l ' ( ( I

DR? TEROAT Jor HOARSENESS) 1112 v ~

HORTNESS OF BREATH ~ v rv ~✓ ~ ,

--5 il D1SCR43Gc, /

.*_ T

G

:ST_p :1 /V ~~/1 ((

- E ..u11`rG

--EST TIGHTNESS /

- S m R; C ~'Tp~T (o Rol /0 p~ (/

\

" l

\

__ IoJ E

I I

_ DAC LL L

D NTiL : iro Y E S

7 IRRITATION I i ~ I 1 r I ~

-- E 3 SYMPTOMS

!LIST)

~

"mp i.oms' & d1scCP :o ; L

_ d several nours,

they c ause you to :

- to _4-3 )

Decrease optional or recre a tional 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 1d duties )

Stay at home sick(lose sick time from ::or k )v

Visit your physicia n

Visit an emer, .^.c•r room
p.17

o r D.

c G r: ` <

co R INc

~2(0~' ~+ z CO Co

1= NON E '2 0 :oD C c c; C-1 C.)

~ -0 ^ C 7

3 0= J E V :' : _+ . : ~= GZ r= cn 1 Co 0

o=.lf I I, y~ `_O_ i_'l l 1, ~rn ~ ~ .. ~_ ~ . x

' i-~ •~ F-.

.

n

.,,. ~i _

~ UC_ q

?UT UM /

J,',S" E°''I_^-' So F

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_~ ZTNG z

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, -,IT 1_ L .. 0

y~ J ----, l ~ r~i ^~ MS (f ` ~ \ II I ~

^ oli7s is CiiSCcrG_Or. .

s `TrZ :'31 hours , - ~~ -

t a e , cause you to :

- ~o a-3 )

Dec=°a sE' o p ,io c a i or r°c"°°i,?onz j acti-viltf List

Take additional Q1eQ'_ca z io n

Be unable to _ner=ora the aa .ci m u ;a amount o : work that y ou could nor m ally

Der-For m

"urn this workload 1e v e l do v n(di sre g ard fatigue )

Be unable to oerLorn your usual :ror`zj activity or Le ,re1 of DrCaucLlVl -t l

occuoa t ion, school-work., critical household duties )

Stay v a t 7oIIle s :Ci( j ose sick t 1'.1'`' from - o r -`- F

'_5=~ yOli : Dn_r5 :__a n

7 -~_
p.18 >G~.

-

;.

'~ /S~;-

D .

~ 3 a ' _ZC

1=?dONE 20OD`zL'

o A

=?-`--C ' 3 0 jYEr . : a - ~

• CrI o] ;7

i~f ii - i _ 1 ^j ~ 7 ^ X F-i r_- Cr) 0

~ i7 ~? o - C X Co v7

U e q -4 ~ f

:'UT-U M

; 's^y3N_-_L SORENESS r t a :Y AR EIN r.S s

E ^~3 0 _1_`,'

uoa.IS ENE sJ ~ i 1 S ~ f

- O llm T~{ ~.`.. S J OF - ~ i

~ .-'_L• D1S CHI_ -H r' E ~

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162

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l+ I 4'(7 jS

CU7

I

N T.^ 11 : N 0 f S

J j 7 O r T n m i0N

7 SI(?d7mQ M

S I ` I ~ l

1 I

=O~.OL75 '

_ several hours,

tae ,r c a use you to

' to A - a

Decrease o D tioaal or recreational activ-it-r List

^a :~e additional medica t io n

Be unable to DerZor m the maximum amount of work that rOll could 10r =. ? 1 1 f

perfor m

i urn t h is workload le v el down(disregard fa- igue )

Be unable to oerform your usual cror k s activitf or level of productivit y

(` occupation, school .or!t, c r

itical hous e = o Id du -, -;es )

St~ 3Y at home :(lose sic lkz ~iae from ~ror :- )y

your on_rsi"= Z

_~= -

.

-- = zf - ~T

~ ^c_r _^] -1
P. 19

C DriD .

c: L.D _-N C x <

L= :do N Z

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CD

i L - n 7 ' X r

`. [.--' G7 ' if] r U] -- - O

1 D=r7LD Q=! NC ~- .'

~ O UG_

S?UTUu 1 5 i 3 UuS^ EnN 1 i, S 0 :EN-ES S

Oa a :Y^_P ::..i:= IS S

SDe Z, n n ~ __ 0 C?

:

or '-;- o^-_'s Z NEE S

:V E SJ Or 3?S ~COR^ 7 n_" ~

i1_S T- D ! cu

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v

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=V~j_~

-

jy~~~ d- ?0 PID 1 y

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_ _~~~~~ ) ~ 1 ► ~ a q T _1_1, : y0

-- ' f j ~ 1 , ;,~

► ! ~

_ se~rer=-1 aours, ~~. . ~ .

t ae 'r Cause Y--U to :

- to A-3 )

Decre 2.se ooLioaz l or recreational zcti~r :t-r List

Take additional atea i ca t -io n

--Be uIIZOlZ to perform the ma :c1 = uII amount o

f

t,o='_t that you Cou '

a ~1or~? 1 1 y

pet-form

iLlr~l ~ :li 5 workload le ,rei QoGtLi(QZSr_ ga ra i3tig ~1° )

Be uazoie to perform your usual wor k j zc t i ,r=tf or 1e , re1 of productt;r

(` occuoaUioa, scaool :or'c, critical house ~_, o Ld duti°_s )

Stay a t home s :c,( L ose sic ~: time frost ' 4, or 1-)v

tr3' vOUr ocl'rs : .1

7~s_ ~r ^c•r -^oZ
p. 20

, ~ ti ~ ~

C ;

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. i.

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? 0 NE 2 0 0 D E ' T .'T, U' U U U U C

= ;

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-D

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= 0 R _'vE SS OF 3 P =~_^ Tl- H

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Cn rr_r^rPN7C,S /

~ --07CT _o N

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_LT

~ ^

---L : NO Y~s / 1 ► ~ t ` ~

T 7 g l

. ~Te m-! Orr

SYMPTOMS

I I

=D .J,~i.s & Q1=c .^,a= o .

seTreral hours , ' - - . . .

c ause you to :

- t o A- 7- )

Decrease oztional or recreational ac .

=a -e additional medilcation.

Sc unable t o DZ :'_arm the maximum amount of work t :lZ -, you could nOr=allY

aeriorm

:':1= 1 :1? S crarkload level QOc: Z ( Q' Sr° - 3r Q i? i-'1e )

Sc unable to De='farm your usual Wor 'St 2Ci.1r1 '. y ar le`rel of productivity

OCCCIDZi,10[]

, s CS1oo1 voL' k , critical household Qlli.': e s )

:ay, =_~ nome s=~'_:(lose sick ci :te :_ oca 'W or

'rou =

2.a -° -

.-.

e

.

..

-

- - -

..r. ./ - --' - ~ ~ _ - .^JC7
p. 21

~ 2_~~

~OCvD .

C ~ ~ C <

3 0 0 a '__dC ~•~Q r^ z cn ~ G2 - X <

!

51=TRACE

=NO NE 2

jC=

00 D -31

S r:v r Ul cI] Ul O :'.

^_

i

T.~ o ^ ~ c

CrI Cf]

~ p=~,r1r.0 ZO -

- -C~_ =~I ~ ~' X r7 }C r X r 3 ¢ ^ C 7_ .

X C a_

=_z

O U GH /v

?U--UM 1 ,

3B S^ERN ^-_ L So~ _-r~s S

) aE TH?O n m

r H 0?_?S E NESS ) 1

10 j

V

S

ORTvESS OF 3?=_-_ q

; A_ T. D EI SC~A -='e~l J

a 5

_T c

`^~ G s:m N :.vJ I

1-a 0

I .j 5 s ~~ ~v /o

-IG J E e

N``~L . NO X~ Y 7 S ~

I3qITim 7 O N

S=_~m) J a SYMPTOMS

_l r ~ ~ ~

~toms & disccia_or .t 1

s e*r e ra1 hours ,

-: hey cause you to :

~o s-a )

--crease oDtionZ l or recreational a c t i7_tr st

a k e additional =Led2.catio n

_ unable to per'orn the maximum amount of ::or k that you could noraallY

erform

. .ra this vor!cload le v el docra(aisregard fatigue )

unable to De'_'=0rm your usual ror k i .'.c t 1Yi ty or 1 e,r°} of Droaucti'ri t V

occuDation, sc li ooL .:orti, critical house :o Ld duties )

:: ay at home s« ._(lose sic l.,- ~iae irom w or~)v

s_c your pn-rs :_~=a
= f(/~`

F p.22~

qZ/i

4 _ •_ • -- -

c

' • - ~. c

'0 HD

c

c .7 a

_

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✓ ! F-i t= h~ H t_ c:

J-~

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73 iC

_

30 S GV Y

E 111

.

-,31 u

^_ c

co . + CIl U ; ~(] U]

D _rtTi. D 4 0=! :dC2_? . x r,' x r' si ~ c

D UGH 6

,JTvu

-3 S^~ RN_^-L SORENESS

Aiv-^-_R -7 Nr.•S S

+

m c ?-

01-

m

_ NO~ :?S E NESS )

DR`"ti E so 0= 3? ;_- ,

5-

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r J

S770N

gC)

~j) S ~U f~ J J~ J l ~ ~ S

T NG a

O

--ET TT s~, 9 NE ss /

-R 7 cm 7 0 if

-- GU-E s 1 ~ l ~ ~ ~ ( 1 ' J

A.C 4 ~

"TI LT : No ►~ Y~ s

ryolT A ' ON ~y ~ ~ I ~ ._ C ( [ l ! ~ `

:~R SY XPmOMS ~ -_- --

73T) -

VOIiS ~t QlSC^,I[1_O . -

s ever al hour s

aey, cause you to :

'. C; o A -3)

--crease o nt ionZl or r e c- 22 Cional activit"r List

=~e additional medicatio n

_ unable to perform the ma :C1^.

.lul1 amount of vork that you Could normally

e : I O Z'm

r II this uor!cload le'rel dotin ( Ci'_si e - aTa ia t 1 g '1e)

= Unable to perform your usual BLOQ~CG1r-r roT'1Li '`C t ir : t y or level o f

0 cC'••2 1) a~i On , sC ho 0~ ~02 C : i 1C31 hous ~ '--o id duties)

- ay a~ home sic :-(Los e sick ci m e from vor :~)v

vOllr D h 'rs___°n
p

. 23 G1J,~~

, ., M ;

~ O'LrD

'

:.D -2 ,;G on

? =_ro NE =0 D E-R, ^_T Z CO C_

__

'O ^303avj3 EE rz on on C L on

t)_+t 1 i. D O= r^ y~ ~ X >G r 3 P ^ C C 0- - :_dC A-?-

c . ^G_

CUGn 1 1 I / / / , (

I

73S?':,: °N_^-_i, SORENES S

3 a:ti_ii_RE N E S S

~NE 0"°'

)r ELO A ?S Z :ILSS ) ` I ' ~ ~ ~ I (

D R m -\l!',SJ a : 3~

J

V

SS'J~SCu_`_?~~ ~

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--7 `, E Z z _ G

~S~_ C m T`o N

"_, 7 GJc:

f I ~ I ! l

D A-C H ~

0 Ci`i'^-_L : N o Y S

? I R qTT"-.`"! C N f J I ~ / + ~~)

_? a

~~toms & di-scc

d se ,re_al hours, { I j ~

.a*or .- ~ ~ ~

f

tae r cause you to : ~ J I

~ to A-3 )

Decrease ootional or recreational zcti ritr r i st

mZ ' -- e additional medication `I B e unable to oer*or :~ the Qa .cimura a m ount o f uor'_i that you cou la norWal l

Deriora

Tura this 'w orrload ie .r e l do~-a(disre g ard fatigue )

Be unable to oe= ior m your usual :ror :tl activity or Le ,rel of D-oauC'ci , r i,:r

occuoation, sc`:ool ,.:o ;v, c :-itical 'aouse :o lo duties )

=_, none .: _ C . _ ( i o _ - 7 , ^o_ 71
----- -• _, s ~- : ~ i - _ p. ,

O rrD . c = ~ z z

CORING co

1- c C

1 =!IOnTi 200 DER ^- -`,'T' c ' E ' 0 cc co ~ r^ c O Ec ,

5=TRACE 30=5aVE E- .°.~: S=7 ~:

] E t= C- CJ 0-'~iz.D LO=~i~C?? . x X f!? C

O -

-- . a. --- c _

O UGE ~ i 1 0

?

UTcM

J3S'!'ERIv ^I, SORENES S

I a:yaRENESS ~ 1 1 ( ~ E ~~ ~ I

)RE '.° iRo .^-_ m

jr AM'SENESS ) J , ~ ~ I I ' 1 D J r1

:ORmNESS OF BREATH

l v I O f 1 ~/ / 0

_SAL DISCsAaGZ /

, NG LS T To q

I ~ Io 4 1 101 lb /0 1011D

mL u ac L(H_o(o i~ 10

.EST Tl sR c~ T ~r J

R

-

CT

_

O

y ss/

E)

TI G s r

AD A W:

ONT^_L : NO Y~S ( I (

--Al

E I3RIT_^-_m ION

HER SYY? TO M

S (LIST) ~ I

T=

_

p LoIIs & Q1sC^rS_ - ~

several hours ,

taer cause you to : I l I /

r t o A-a )

Decrease ootiona! or recreational activity

Take add= ;,ional medicatio n

-Be unable to perform Me maximum amount of F-J ;k that you could normal![

perfor m

Turn t:11s Gor Yl o a G ' leVei Qo': n( QisreoarQ fatigue )

Be unable to perform your usual Gorii activity or level of p rCauctl'r'- t .r

P oCC'iDZ`' ! on , sC .7ooL o rk , -critical Qous a ^o L c_ duties )

.S t Y a! C1C .. .e c_c :_r 1 Oce c_c : t_ ., .` :_cm

,-'_' -•- --•-- - - __~"~
:~_~_ ., :~C ~v ✓

i , ! p2

3~~

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0 ND . `

:.- c c== G: ^- _ '=

0 0 a 7 < < tijC . ~ ~~ ~ z rn c: r < c?. X

1= ;-K 0 N:P 1 0 ='_~ 0 D E R ^- `nE % ` r - ~ U U U U Cc

O & G E C c'= Z c: E y °AC v 30=SEVER-7 c- c c Cn ^,- co cr' ~- ~ : m o e: m cr3

r~=r~Tr.D LO=~YC~_° . x E; x

C=

: x x a ~ c

O UG H

U~ UM_

J_

JBS^ER N_^-_ L SO RE NESS r /

R a.Ya_R ENr,SJ J~ 1 !J ~ ~ ~ I 1,

III

i

/

)RE

Jl HOA.01Sr: :IES S

S TH

~Ss T- D ; S ; HARG L /

)NGr:S T 10 LIT

:1 7zl jrc

E' S T T10_""_V?SS

S':,q, ! c" ' 0 !4

-T GUr~)

JKT^_L : NO

Z IR~l

r =S J "

p ~r

1~1^ m! 0 IV

T

.'E'ER S f~~ PTaMS

~ ~ ~m~ ~ -

notocis& aisco

2 se v eral hour

~_o,

s

.t ~ ~

they cause you t o

t o s- _a )

Dec =-ease ootional or rec :-_ational zcti v it-r List

Ta :~e add~tionG_ medicatio n

-Be unable to ee -~-=or m t h e maximum amoun t of work that You ccul ^

n ertor;u

Turn this woroac le~rel do~:a(a=sregard i a ti g ue )

Be unable i.0 C? form your usual rOTil 2Cti'r r or 1 e

rol Oi DrO~ucO'r, T

--e-E )

OCOu_ a z _On, ~_ c :Qol ~'OC:"_t ica~ ClOu°_ °-^_O }_ O u t

a :; home

_

'r-=-~ ~-- • =----•-

.''-- _ ~ _•- ----- - - .
p. 26

CO l'l _./ • T r. L ~ ! ~^

L ORI yl~ L' i C14 CZ

L='iON!: 2=_:CDc:~"`~`E_ c: c: c c

:=?'R ACE 30=Sc:7 -E° : vEi m c C-_ ~c ^

; 0='{7D L0=-=vC A°

_

. X ~ ~-X c X c c-x- x ~ ^ c c ~

o 0U G= ~ ; , ~ r 1 ~ t ► j ~

3?_ E UmUu

ii0t~?

or E0 A.'S E~qESS ) S

i ~ ' ~ i ~ ' ! J 1 f

cOP.-~ Y1SS O r

'-'--S A!_~. D 7 SC ; `-_ ;:,C3 /

_9 e=ST= 0 h

I m

j o /D jo 1 0

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.~

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.r.

_ r- "'~~~_,- - / { \

_~-~~~~, .~ ; V ~ ` ~ ~ 1L~ l~ '✓ ]~ ~~ ~~ ~~ !

v G v V

=_ -n~ m=o y

5 7 ,.f_

_v . 1

i L _~ cons ~ discc M. 'or.t

taer cause yeu to :

t o

Dec-ease oDLioazl or r°c .-entionzl zetis:.t_, List

Tase adnitioaal me d ic z tio n

-Be unable t a DZr :orm the mS :Cl m t1I7 ZlIIoun z of GO~ i that Vou c ;Ju~ noL' 1 1 f

oe= ior ~

^u_a t ," is G;ot-!~1oad Le ,re l doc:n(ai sreg=._d _ a- ig~e )

3e uIIZ01~ t o De='oT- a our usual GoT' l{1 2c t 1`rit ; or LeYeL Oi DiC'uCLlr~Lf

P oc OUD2 t ion, sc H oaL ::(J r, cr_tica l houEe =c Lc du z; _=s )

'-~-- _-- --•---- --'~^
SUBJECT (~~ ` l ( ~~ / //► L

N0 .

DATE 4-d- H H w ~ ~

O C~ z z w wz

COND .

0

3 H H H f-H a a a .i w 14 ~4

H W W0 W

SCORING D. ~~• ~ a~ z ~~, H H H H H (x ¢ x Q

1=NONE 2 MODER4TE ~ E' o o c~

5=TRACE 30=SEVERE w Ro x a H rz H rz E-+ F, F+ a

. ~ w Cn W M m o w Cn cn ~

10=MILD 1+0=INCAP . w x H x W x w x w w a o o ~

3 w a w cz w rz w a ~ ~ a w U

COUGH ~ 1 j 1 ~ ( ~ ~ l I 1 j

SPUTUM ' l ( I ( ( f ~ /

1 / 1

'

SUBSTERNAL SORENES S

OR AWARENESS

SORE THROA T

(or HOARSENESS) I I I I ' ` ~ / I ( ~

I

SHORTNESS OF BREAT H

NASAL DISCHARGE /

CONGESTION ' ( r C / l I

WHEEZING

C HEST TIGHTNESS/ q

PESTRICTION 1 J' ~~7 ~ 1

~'ATIGUE \ J 1 ~ I / !

=EADACHE 1 (

FRONTAL : NO YES

, I ( ~

EYE IRRITATIO N

--`THER SYMPTOMS , ( ` (

( (LIST) ` ( ~ f I

symptoms & disccufort

ted several hours ,

_ld they cause you to

fer to A-H

: 1 ~ 1 I

)

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 id duties )

Stay at home sick(lose sic,_ time from workr

Vvour 1 ci- .

r

~.~~~ _ t an
p. 28

::;

- ~-

- cr c= z

~

c ? ~- ~ r= r=

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._--C-, 30=ScVE3L M Co ' i=T'_° :=-- U1 01 CO

.1= M

- L i= X I~ }~ C X X !L i~ O-7- S`lCc-P .

.r3 W C o~Q - G-

~UG=

'

U T `'~`

'3S^y3NA1 SORENESS

A. EN rS S

?ir. ":' ER 0 AL "'

J

r H o^R s ENLss ) ~~~ I I 1 ! I

ORTYE SS OF ^^ H

~r_L 0 -7SCSa?C7-/

:YC- °_"_O N

G

S

=' H7,- ==0 N

~

1 ' , 1 i )

,'( T N O

~ V" m n m~ 7 1 I ~

~

R, S o v s

~~oCS gc Qisc .^r3P.~Or.~ ~ `

se v _ . a 1 aours ,

~ae_r cause you to :\v

) ( to 1-a •ec : e =se ontioazl or recreational activity List

:ak.e additional medicatio n

e unable to aer=orm the ma :Ci m u:1 amount of work tha ~ You could

errU r ~

.!ra t h is vorkload leTel doGZ(disregard fatigue )

u :-0i-2 to De- :.or your usual ror:tj 2-cti7= t

_r or 1 e 'r _ L 0f P r^d uczi'%~ .r

occ ina ;ion, school ::or!~, c- :~ic a _ ho us e^c 1c cu~i_s )

a`r ~7: „o,,._ s`_.(?os sC ._ 7. Z_ _, .. .. . -o )v

: ~L'_ z 2 _3 . .

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p. 29

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.

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c cr ~

cc M

=147 L 0 L:O=_N C , ? . x x

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a UTUM

_

i.S^F

a :Y AR

..3VA!t SIOR

"NESS

EtiT ;SS I

a~a 0 a_m

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'R~irSS OF B~L='-^-_`'R

DE s CHA?,c~./

" O N

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C= ~

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sever~1 hour

.~ ~ )

;r cause you to s --ae :

to _4-a )

ec-ease outionzl or recreational activit-r List

a`-:e aaaitionz? uied.ica ~io n

unable to Der-form the ma_ci mu a amount o f work that you could aorma1? .r

rior~ -

this vor~zl08.G le`reL Qowil(aisre-2ra fat- -' )

r Loral your usual vOr`.S1 2c~1'r' iy or 1°'r°- Oi OrCal2CL1 r-"runable to nC

oCCuc'2tiOLl ~C700 ~~Or~ C ;-_L 1C3 l

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p. 30

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c. c=

OUG3

j ' , I ~ I ' \

"' UTUM

j 3STERNAL SORENESS

AWARENESS ~ J l

'-RE TQROAT I

I

r HOARSENESS)

ORTNESS OF BREATH

.SAL DISCHARGE/

1/ 0

?T GrSTIO N

=EZING

-~ST TIGHTNESS / T RICT roy

__GJ E

= 7,T-,'L- NO Y Z

S

IRRITATION

=?R SYMPTOMS J 1 l '

( ( ` ~ ( !iST ) l 1 , \

= -D tOmS &

several hours, I '

discomfort, l ~

( 1 ~

they- cause you to :

to .4-E )

Decrease optional or recreational activity List

=ake additional medicatio n

be unable to perform the maxi mum amount of work that you could normally

-jerform

=urn this workload level doun(disreSard fatigue )

be unable to oerform your usual work* activity or level of produc'ti'rit :r

{ occuDation )sc}7ool'w or{ , critical household d'a' ties )

tav at ho me s f .- i ose s_c_; '1` o~ W o

your ph r~ _ c _ a

s_ . a .- -T, -- -7-1 C Y 7,:_, ~n
(,~~ :Z V~J ~y / ~ 31

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c G.---~. M r4 z

&

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C4

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C7V

/

O /v (V

; iJBSTL.°.NAL SORENES S

) R AWARENESS , ~ / ) ~ ~ I r (

1 ~

(

ORE TEROAT

or HOARSENESS)

HORTNESS OF BREATH

ASAL DISCHARGE/

ONGEST?'O N

HEEZl'-dG

HEST TIGHTNESS /

E ST R--*' CTTGV ~ l ( ! ( ( ~ ! ( (

^-T1GU~;

7

R

.

GNTnL

'-~D~Cu~ ~

: NO Y

E

S

YE IRRITATION

/ ~ ~ I ~ ( ( ( l

--HER SY MPTOM S

(LIST)

: m p toms & disccmfor.t

ed several hours, ---

d they cause you to :

er to 'A-E )

Decre a se optional or recreational activity List

Take addi t ional medicatio n

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

perform

Turn this workload level down(disregard fa ti c- ue )

Be unable to perform vour usual work* activiti or le v el of productivity

({ occuoation, school w ork, critical house'.-_o Id duties )

Stay at ho m e sic'-r(lose sick time fro m

V J .

. V l7 U r .-~ j - C i .~ 1 •

V~s_ . an ?- C `_'oOli.
p. 32

°mJ ~ z

'OND . rr ~ '- z z z =

o ~ ~

I-' C-: p E"

CODLyC

1=!IONE 20= MODER_"TL

a

Cf)

cc z u

ci

a a

v

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~v U

5=TRACL 30=SEVERE a a ca, cEn P: Co Co z U F F~Cn 0=MILD 0='_NCi~T~ . F4

i Gx -7 }C P. p C~

a4

U

OUG3 ~/ /0 iv ? 110 /Cj )

I ~' r ~ ~C

PUTUM

~c C/ ( 0 l1, ~

UBSTERNAL SORENES S

R AWARENESS I l I ~ , ~ I

O RE TLROA T

~r HOARSENESS )

:ORTNESS OF BREAT H

?SAL DISCHARGE /

) NGrSTION

S ~ I 5 5 `~ J ~ ~~ 'C~

_ E L ZIN G

.i,ST T! GH TN ES S /

:STqIC^' 7 0N

r 7 Ci.lE

' DACR= l

ONTnL : NO Y~S I ( I / I I r f ~ ~

: InRITATIO11

HER SYMPTOMS

(LIST )

mptoms & disccr=ar~ I~~

,d several hours , ~r - --- -

they cause you to

) : r to A-T

Decre a se 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 dovn(disregard fatigue )

Be unable to perform your usual work* acti-rity or level of producti=rity

( occuoati on , schoolwork, critical house^o ld duties )

Stay at home sic-(lose sick time from

your
V~' p

.33

C •

' .7 ND .

003~ :YC =^ z ^ ~- ~, `

? = ~I O N E 20=MOD R. :?' - ^~ i

~---o A

30=Sr vEa~ ECII •- 7

0=''~ '!~ D L 0 :1 C~_? ~ c x x ~ x ~' G? c c- Cf:

OUG =

?U TUu

JBS"y3NeL SO RENESS

3 a:tir?.uNFS S

7Rr^. '-' E30 :i`i'

ffOA.DSI :tLSS )

1-5-

=ORm'Y I-: SS 0 7 3 V37 ~m_ H

_ L?

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/0 s

T N G

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0 _ T rNO ~~~

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r

• - SY'r--~~n cr,~ c

( y I J T -= - -- l - - `-- - _- - -

II~~OIIS 3c disc^rR'or L

_ se v er=1 hours,

the_r c a use you to

r to A-3 )

Dec=-ease optional or recreational activit-r List

Take additional medic a tio n

-Be unable to per--or= t h e maximum amoun z Of u-or'.: that you could normally

oeriorm _

iu rz this voric-Load leve l down( di s regard L'3 t i g •a )

Be unable to De'_'iorII your usual Wor k ac- 1'r ;L! or 1 er ol of u r .^•auC t "rit -r

ocC'uD2 t i an , sC70o j :OI' ii

, C ;'ii,1C3 ! ~:GuSO L du ~=_s )

5 .

.3 J at '10C: _ s - L o .: z2 s -C

~ y O u r

'~_= _ ~ _ .- --•-- - - - -'~~
p. 34

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0

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TU

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-_~ ^C "Z =

`r ^_,, - v o

; Tmnm _ Q rj

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p LOra s ~c a.iscOrlr Or .t

several hours,

they cause you to :

Decre a se o p Lioazl or r e craatioaal activity T.

i2k e additional medicatio n

Be unable to perform the maximum 2tIlou'1 z of G"O rl•: that you could nOr•u a } lV

oerior a

Tsrn t h is wor!~: loac 1e ,re1 doun ( disreg a rd fatB e unable to perform Vollr usual vor :Ll activity or l e•fel of u rOauC`r' iv - 'r

oc0'1D2 ti On , sc .^.OOI w 0t"'- , c _ ' _ i , i c 3 l tlOus ~2 _1o l d d u t i e s )

3j _ ❑ OC _ S _ osti s 1C .- ~ _ ., .- - -c c ' "o

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.

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5; `UTG M

OR a:Y A-PE:: '.S S

SO Ct^. ic`.0 A T

or EO^-_RSzINiSS 7

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5- 5

i

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i I

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tJins- C :SCC :_ _

52Tr2rI f OLTr <

tae_r cause you to :

.- t o

Dec :-ease oationzl or recreational zctirit'r Lst

' Take additional medicatio n

Be unable to oer_ora the ma :ci = uca amouaz o : u-or'.: t . at vou could aor~ -~ i 7

nerior m

7iu~:i t :11S Go(J2.d Lere L QoC:a(Q? s r e g :: :'Q fatigue )

B e -unable to pe-form your usual 4or :ti zcti'ri t-,r or Le,re' of oroducLiri, :r

( occuoa",ion, sc7ooL,.:or!<, cr :tica? housz~'-o 1c cuZ:'_°s

~u-

~-- -

._,, ;M.
p. 36

1-3

c c z

: OIZD .

. . L ` -

C

i i, 0,°, ! :q*G - C7 ! < }C ¢

1='SON E 20=•_.0D ER ""' E M C

C -_---~vr~~ .c--+D n ^ O = L'' E+ C E~ c= Z

30=Sc ~

r- e c c m CO Cn o c-;

0=r,r~LD 4o=7- NC -I? .

.= G: c: x ::- .' ~ c-_ ^ p-. ~. •a- c~

OUGH

PUTliMUBSTE Rti-n--L SOR ETT EE SS R AWARENESS 1 I I ~ ~~~ ~ ~/ L

D t'i". TEROn-`n

RO?RSENESS ) I ' ~~

~. ~ ~ / ( I 1

ORTNESS O r

-S g-T. DESCRARGc,/

KGLST O N

T 'rIG

ES'i, "

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,v ~ 1 I 1 I r ~ t ~ f /

'_Gil

Na

7 E3~SY'-.1PmOMS

-- -- ~ ~

7 t oIIS ~ d15C^I~ Or.t

several hours ~ ° -

they cause you t o

to A -3 )

Decrease ootioeal or recreational 2-CtiVit-,r List

Take additional medicatio n

B e unable to perform th e maximum amount a i- vOr 1i

that YOCL cOll l G L10rW2- ll- f

DerloT" m

~'urn this workload 1e,re1 doGn(di sregard fati,ue )

Be uazble to oe : =or M your usuzl Vor :zl act :-ri t y or Level of D roducti lr= , :r

OC^'1D2 ti Ot7 , aC '100 !'.;O ;''f , C :"_ ~ 1C3 ~- Olls °^C LG QLI t :

a I ? ZC S ., ._

7~ cc
p. 37

/A -A

m

?= YO tN 7- 2 0='_- O D E R^- "'

~r.

E ~% F c= c C t c

3 O =S c J r ~, ~. c(2 Co c_: Co o Cn Ca

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~:i_, c-.X.'.~ f=x: ~

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OUG_

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5

5

JLS^ E?ti_-_L SO R ENES S 3 AWARENESS

)a z `t' L? O ^ m

) r E Oa3Sr,NLSS ) ~ ~ J f I ~ ~ ~ ~ G~

J I~/

)

OR T, Y *_.SS O

T- D TSCsA ?,CE F _S~ /

; NGc:S?' , 0 (i

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IRRITATIO N

S`f`dP mOr,{S

-¢ m

7~oGls ~ QisCCtilr Or .L

5 e v z r 31 hours ~

~•~

taer c ause y'ou l.o .

- to ~?-T )

Decrease optional or recreational zcti v it-_r Li st

'"ate additionz l medi atio n

Be unable to performthe C2.:c1WuCS Zmou[] t of TGOrt that V OIl Could no ?' = 2 -I 1 Y

DerIoT'm

this G'oL' !~:I o3G level Qo ~ : ."-, ( di sr e -3ra fatigue )

Be unable to De^L'Or-z 'rOL 115U=} ~OTtl 2Cti'I' tf or- Level 0i uroducti,r-~-

oCc1D2 -,ion ~ sC .^.o0 L .:Ort, C -- _ -- _C3? QOlls c~ .^-c id Qlli. =es )

time ^,G'

_ rOU~

_ > _ _ _ _ _ _ "_ -_ _ . _ .. l • ~
p. 38

- ~ -- _

C

O NTD .

C ^ >-

_

i"_E

7 0 `za. '. 'C /Z CA G: }--~ G'1 1--i X C =

~-• •' ~' }- 1--~ Y F--+ r. 1--i G-.' U t%

LONE 2a='•:ODE~" A_-_' Cr

O

` U U U , c

:=`R_-_ C 7_ 30=SEVERE c: c; c-: rn r- m G cn o c; m ~` )=+,rT T.D. L:0--, - :~C_~ X ~

G=

i 1 >U GE f)n 10 { 1)(v

`J T~` Q ( 1 dc ~ ) ~. -2 ( O - c

BS" E3NAi, SORENES S

AWARENESS 10 O~ ~ S ~D

-

;1 _

L'

.

~C70n m

" HO_-_RSr NESS ) /

o

7R T NESS OF 3R~'^_~~

J

~~ '10

V'-L. DE sC: A ?c~. /

i U

~• I _cL S T~oY l { i r~

cl

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r-a

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r

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-iy J y f I ~ / ~ ~ f ~ ~ ! ( !

J a

S'r' rD T p,r S -.__-, --

I

ta~s

& several hours, ~~ \ \ n

tae :r cause you to :

to A -a) ~ c5

-c-ease ootioeai or recreational zctiritl L_st ^ 30 ~--

tie additional medicatio n

_ uIIaDle to De"=orm the C12 :C1wuIl aQ10LLCit O : GOL :i .1? ~ Iou could noI' .~.~? 1 f

_u this uor~:load le,rei do :r; (dis:egard f= z i =_ e )

~unable to oe~-ior~ your usual Gor .i act_•r±t-r or 1e ,re of p roducr'-'r-~,r

occuD2_ tion, sc h o0 L : :o r `:, c r_ . . ic3 l hOL'S _ ._ 1 Gll- _~ )

a home s_z_ (1O s e --- ._

ll= C = __ --

_
L i~~

p

.39

IL -

A. TE - cJH r ~v z z

OND .

~ pLYJ~

1- 4 p ~ E ~

C OR I YG Cl] H G'~ H X ~• •-

!=NONE 20=MODER_^-_y

_`~ O U C

5=TRACL 30=SEVERE a

0=•'_~ILD 40=INCAR . c~ X H X c X X c ~ m o c E m

: v. ~ o C

OUG3

PUTUM ' ~r r

U3STiRNAL SORENESS

R AWARENESS f ( l ' ~

D RE TEROA

r HOARSENESS T o )

=ORTNESS OF BREATH r I ( r ~ , ~ / 1 r_

kSr?L DISCHARGE /

)NG ESTION

iEEZING

:_^-'..ST TIGHTNESS/

STR! C"_'I0 v

_TIGJ-E I I I ~ f , i ~

:~_ D ACQ 7

OKT AL : NO Y:1:S

i IRRITATION

HER SYMPTOMS

(LIST )

rmptoms & disccmior.t ~

ed several hours ,

i th ey cause you to

! r to .4-T )

Decrease optional or recre a tional 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 doGn(disregard fatigue )

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

occupation, school-work, critical houselo Id ciuti--s )

Stay at ho m e s_c':( I ose sick t_ ., ._ from

V 'y'oa_ . _rc ` _. .
p. 40

ATE • /~/ C ( ~ !~ r- =

_ ~% C Z Z

O N17 .

~ j

O ~ ~ ~=

C 0 R

1=NO

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G ~-/~ o~'t0~ a z CO

1_ ..

a: <

c ~

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0=MILD 4 O=INCA-P . ,

C p- G'

; x X ~ x c; a o c. C_

aUGa

PUTUM

iT3STE.°,NAL SORENESS

R AWARENES S

ORE THROAT

or HO ARS ENESS )

HORTNESS OF BREATH l ~ ~ ~ I ( I ~

ASAL DISCHARGE /

ONGESTION

EEEZING

-EST TIGHTNESS /

:, STR!CTION

GU E

-'_DACuE

:ONTAL : NO YE

S _E IRRITATIO N

'HER SYMPTOMS

(LIST)

:-m n toms & disccr~_or ~ I u

several hours, ( I' ~ I ~ ~ ~

they cause you to :

er to 'A-FE )

Decrease optional or r e cre a tional activity List

Take additional medicatio n

_Be unable to per-form the maximum amount of uor!~ that you could normal!v

perfor m

Tura this workload level down( ciis regard iat'_gue )

Be unable to perform your usua l work* activity or l eve l of DT'oQllCL1'r1 t-r

ocCuDatlon , schoo l -work , critical tlouse^o i rS alli,les )

S t ay at home s_C!r(loSe SICK Z;i :1 e from -wo-")_

V'_ Voll :

an
p.41

nm,~ `6

rl

( -_

.

. V

DUD . r- - ~= c z ;--F _

z

` Z ^- ~-•

:00 !-qG CI-f A . V Co < f'' G~ ~p y~ c

_ =NONE 20=MODE A M ~ U% L -? ~'"~ i F -j C;

-m _v O C-- E

E- C)

c z U G ~

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L_ x "1 c CO c: Co o

:=MILD l~ p = ! :T C ~ Cc ~.

x

r=: a

- cP-. Cr-

~

; UG3

. fmUM

_ 1l ~ (

"3STS°N4L SO RE N ES S

A:v a3 E,It :?-:SS

-E TER OAT

fio A°Sc,rrESS )

) L1TNr,SJ OF BR i.ArE r ~ 1 I ( I ~ I 1 + ~ r ~

-1L D! SC34R Cc, /

-- G'E Sm ; O N

7 T T_ rf ilTNLSJ

, C^_'IO_v

c~ ~

'-T-L : NO

j' RR77 n,m1 ON

° S f'ip^OMS

=! S T

-ototas & disccr_cr~ 1

se v eral hours, 1 \ I I J ~ I ~ I

z he r cause you to : ~ ~ I\ f

tJ A -r7 ) I

,ecrease optional or recreational

-ake additional medicatio n

-, e unable to De'-"_oI' . 'i. the maximum 2Wo11 : z: of 4" or `

t

;-12~ you could normally

=' erlorm

1ra t h is c :or!:load level do v a(disre_a_d i=t :=ue )

--e un able to perfor m your usual G'ork' aCti'r'_tr or level 0 : : cducc~'ritr

• occas2tioc, sc :ooL,:or!c, cr_tica_ hcucz2'.^_c 1 cies )

Z: a,r at nou,, e

-_-- _•• ------' ~c-~~~ :
p. 42

AT+f , ~'/,

~ :: 'in~'

`

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2 0

CC

! =>~OY~' 3^-^L U% C.) c

E' E' L U ~ CU 3

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1If 1 1 4

~ 1 i 4 7 f,i'~ [~ x

~-• (f

~

~___~D 0-__~C~_ o CG-=

) UG7

'UTUM

i3STL'° NAL SORENESS

AWARENES S

IRE Ti-Hod_T ~

r EOARSc,NESJ ) ( I ( 1 ( ~ / ~

.O L1m. :'1N.SJ OF B C`i.

71T i

.S A- L D E SCsaR cE /

rrc Ls T 7 0 ~ ~

E Z LvG i 1 ~~ t ~ ► / ~ ~ ~/

EST T! Cri1 TNiSC, /

sT R7 c r77 O N / / , ~ ( I 1 ~ (

T TG;.r -7

OKTCL : NO

Z IR RTTA"'TO N j ~ J ~ I ~ l ~ l (

3E3 S Y'ApTOM S

L! S`r' )

mo toms & discc m=or.t

a several hours ,

r

they- cause you to

to A- Ff )

: ~ ) I

Decrease ortional or recreational activit•r Lis~

Take additional medicatio n

Be unable to oer :orm the maximum amouaz of wo~'%- that you could ncr=a!!Y

perfor m

Turn this Gior'rloaQ level down( disregard Latigue )

4ror~c- acti•ri or level of rroducti Be unable to re- or your usua ritr l

(i occuoatio : sc :ool : :ork, c :_tical hous..co 1 d-i~ie =_)

Sta_r at noc - =lose sic .- =-

1_ ~

I

: c 7~o ;:
• , i~ ~ /'y~~ p . 43 ~~

.

GROU P

SUBJECT N0 . D ~ !~ 3

DATECOND .

ra c

C

V r; ~, H z

W a z

E- c o r~ E- a

a

SCORING P. r^.,z co u] H co ~ X <

i=NONE 20=MODERAT E RATE co F 0 ~

5=TRACE 30=SEVER!? 0.: c G_a,-, F' F a Ez v E, cr

10=MILD 40=INCAP . x w X CC J=

a c.~ r~ ca a ° cc o

COUG H

S PUTU M

H11

SUBSTERNAL SORENES

S OR AWARENES

S SORE THROAT`c

; or ::o~.RSE ::L s

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

NASAL DISC : A~GE„ J

CONGESmIO_Z t ~ , ~ r ( ( ~ 1

WHEEZING J I I ~ I ( ( J ~ /

CHEST TIGHTNESS/ I]

RESTRICTION ` ~~ ( I i l ( (LL

FATIGUE ~ ~

HFADAC :: f

FRONTAL : NO ~'ES I

E Y R TRvlTnmr

- _ ,

OTHER SYMF`i'OITE

(LIST)

If sy'm-otoms & disccm=ort

-asted several hours ,

vould they cause you to : l ,I I I ~

-Refer to A-rT )

A . Decrease o_i:iona_ or recreational activity List

B . Take additional medicatio n

C . Be unable _o Der°orm the maxi m um amount of work that you could normally

perfor

. Turn m D _s rcrk=oad le-,-el dcs,n(disregard iatic-u

Q )

~ . He u :_ab = -- '~_ u s ; e=' - r - 1 wor`{ a c t or level o= p_ ^^C'. I _ '✓ = t

c _ - „-c a l h Cus e

i

n0".- ,~

-
p. 44

u . _

, _m'-~+ • 3-~ ~ ~ C ~ ~

^

c

z

z

KD

<

0 0 ; NG c

H ~-

a m 1-4 CO

: r-: •r. r-; -- c;

=NONE 20 =MOD E -RI=_"_'y V' 0 U U C .)

-~R_1. C ; T-+o 7

v

a [-~ E•

-_ 30=SrI~ l ,L C~: c r4- Ca vi ;_~ m

.,r ~ = ~ D L I~ -~ r~, x F ; 0 - = y C ; x ~ x r' 7<

i) UG 3 .~ f ! (

! ~

U'"Ulu

! 3STL°NAL SORENESS

AWARENESS ~ ~ ( I ~ l f (

1 I

HE THROA T

" : O RT!Y E SS OM BRL~TE

~e?L 1; 7 SCE~-R GL/

:rGe,S T IO N

iZlidG I I ( J ~ ~

ST TIGHTNESS / ~ ~

- "

`~ T Cm j 0 L~

G J : I~ l 1~ ! f r (

_ D ~Cu E

:T iL : NO YLS ~

IE RIT?_TIO N

SYM DmO M S

ST )

toms & aisc Cm rcr~

^ several hour s

~he ;r cause you t o

to

- cre a se ootional or recre a tional zc t ivit-r List

_a kl e additional medicatio n

e unable to per`orm the maximum amount of cror k t ~at you ceu'_d r.orwa? 11

:~ eriorm

:sra this uorkioad level d.oc:n(disre g ard :atigue )

unable to oer f orm y our usual work' activity or level of P

rcaucLl'ritr

occ a .,ion, s c ^col -.:cr'_t, critical nouseco 1c, du .. )

::a v a- home s

-

( ose s_ct, t_ .. ._ o )~

- - : I

._ - '-

-~-~ _- ~---- -_- --o~
p. 45

GROUP J- VJ~

SUB jECT NO

. DATE

~ c~ z z

COND .

z z e *=

F • a t-± w O W w W H Hi

f~ f~ Z ¢a a

SCORING a• ~ I--i H H H H Gco co H co x

H U U: C

1=NONE 20= M ODERATi c~ o

10=

5=TRACE 30=SEVERE

M ILD 40=LNCAP . `

C4

r r a w a W cz

~ w cEn

-q x ~' x w x e a ,z o 0

co w c~n o w m

Crw r~ o a c,., n c

~ it)

COUGH

«I ~

SPUTUM

SUBSTERNAL SORENES S

OR AWARENESS ( r ~!f

SORE THRCAT

(or HOARSENESS:)/

+ l t/ (

SHORTNESS OF BREATH

NASAL DISCHARGE /

CONG E STTON 1

WHEEZING

CHEST TIGHTNESS

/ RESTRICTION (

FATIGU E

HEADACH E

FRONTAL : NO YE S

EYE IRRI`I?. T TO :

OTHER S YMDmo M s

( L I S T )

Sy/ .T.?iO~S P discomfor t

_ asted several hours, ( 1 ' ( (

:ould they cause you to :

Refer to A-H) ~ (((

A . Decrease optional or recre a tional activity Lis t

B . Take additicnal medicatio n

C . Be unable to perform t h e maximum amount of work that you could normally

p er f or m

D . Turn this .: ..'_' L

-load level CC4." :7~Qls :'eao - a r .^ _ az "~ i^ )

He unable "0 :.r usual wO r __ a c

~ 0 C 2 uDa~ s C'- 0 0 _ -w C :"-, c - - .._c3= i.C 1 :~

- . .:. ~ _ a _ o C e s
p.46

SiTJECT rZ) . y~, Borg

;

DATE Exertion

/ C'i~i C^ Z z~

w

,

COND .

)11( 2 r-4 [--, Scale `'~' H

SCORING w

- ~ m.- a' '~ ~ `~ ~ Cl) ~ 0---No thing

1-~r E 20 _ 3SD~1

U

E-4 ~ ~ ~ M at all

S=TRA_CE 30=S'c V~'~E ~71 o 0 cr~

1.0=_^~D 40=~CAP .

0 . 5 =very, Verl

Little

COL(4i 1= Verry light

SPUTUM 2= Light

s'~BSZ~i~al - . soR=ss

DR AjiP=, TESS

:€ :ate

= j',Ind

.E =OAT eOP

(or HOA_RS_SS) 1 t f ~ Sosa..,-nat

Heavy

31HOR_T~SS OF I

116= tiaavv

IS

:ONGEST_ON 7 to Q

Very Heavy

HE= I11 TG

I~ I 1~ ~ I f I~`~' I 10= Very, Very

:EST TI(3~Ii~lESS/ ~ Heavy

ESTRICTION

ATIGUE E40 .

4-E

_ tl! ~ ~ ~T~~ ~~ RONTP.I, NO YES

1 t f S~~ . ~

.~- ~~TA,,TTON

T1 s~TONS

LIST

) ORG EX=ON

:a.1.~ (0-10)

~

f symDtoms & disc=-fort

3sted several hours ® wool

:)uld they cause yc, l to

•~ ~~,- _~,~ i I =,~ - --~ - -

Decrease optional or recreational activity Lis t

Take additional 7-~edication

3e unable to preform the ma-,.:L7 ,rn =nunt of work that you could normally per-form

11r.1 this workload level Y~disregard fatigue)

unable to perform your usual work activity or level of productivity

ocespati on, s c~^colw=k, critical household duties)

IV at home sick (lose sick f--r=

your physician

ar: =C-- rcc:q
S'E'_FTi H SiGREE Sir= p. 47

1B.JEC'T

.••~ +

)

~ E~xe~rtion

rm .

fndl ,--t c1 l cn Scale

bRIN('

cwn cw M

HH i Ii'~

r-1 H N F-1 Cn

-WNE 20=~DERATE ~othjng E--4

=TRACE 30=S~E ~~: 0R 1 at all

., a a°

)=`_~,D 40=1N('.AP . 0 . 5=very, Ve _7-7 Little

Very light

LL I

~ ~

2= Light BS~RT?AL SORENESS ~

• 14-14M• 3= S Moderate

RE THROAT

r H~~?,RSF'~T~'C g ~ to 5

> ,

=

hat

oxMSS Heavy

16 Heavy SAL DTSU1-L4.R' E/ + I 1

NG~ 'r5 TION 7 to9

I~V ~ I i ~ ~~ 1 r Heavy EvZING Ve. ~

~~~~ltll) ~~~ I 10=_ Ver-y, Very

EST TIGHMESS /

SMIG I'ION Heavy

,

~~

DNTr•.L : NO YES

1 1 ) I ; I ;~~ t~~! ~ ~ RL I~T?ON

I 1(~ i ~

I I I I I

-ER S'd, 'IDNS

:ST)

~

'•G EXE _`T'ION

3

~T-F

symptoms

(0-10 )

& discomrort ~ I

I 11, I ted several hours, /

i1d they cause you to

I J _ _,~

Decrease optional or recreational activity Lis t

Take additional medication

Be triable to preform the s~~-

.

n= =.Lmt of work tha; t you could normally perform 'I Lzrn this workll oad level ecc„n1aisre~ard fatigue)

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

(* occi-mation, schoolwork , c^ tical household duties)

Stay at home sick (lose sic'_{ time from Tr -O r?-c)

Visic your Dhysici=r:

V:s _ : an E^er~e^c~i rccm
~ r. .

,~._c 4&

~ • _ &la OUP ON< l 1

BJEGT N0 . (~°

T

Borg

C~ Exertion

I~ID . z,o r+ c „

., M -4 ' Scale

MEM H L~ w w w H

r-a H N H ' =d ^

r' .^

Mr E 20=N-DDERATE U 0,-Nothing n

c

E-4

i~ cHr~ E--4 aat a 1 t

Il~?~ 30=Sr-=, v cn

v

a

a

o

w c~ a w a ~ , ~, o

a

40==AP . ( 0 . 5=Very,very

Little

~ I 1 ; ~ LS I 1= Very IiQn - -S] ~ t

I LL 12= i.ig~nt3S=- !Ai, SORzNtrSS

3= 't'4der_t

4

~

to 5 =

~ ( ! I, ~ c T_.

Ij

Or BRE~ `rT i , I~ I ! I ,

'AL

i,T 7 to

7 7 7

VCr-~/ ~G~.~•I'J

110=

-

~L~c„~ I+ ~ i,

Ve~-7 , ve_--

i ~E?v~~ =' CTTON

'-=

~,~- _\ I I I 1 I I

~ ~ ~ I 1 ~ ( i ( I ~ I 3 1 l i i !

I I I

(0_10)

sy=t~.s & disc=~fort + + + I i

ted several hours, ✓ l, +

Id they cause you to I +++ - ~ l,l

Decrease oDtional or recreational activitv Lis t

fake additional_ medication

Be unable to preform the ma.,n-"Trn aTOL. .~t of work that you could normally perform

I`Lan this workload level aH., (disre~~d fatiTse)

Be t~a-~ to perform youi- usual work "'activity orer level of productivity

(` occuDation, sc^oolwork, critical household duties )

Stay at home sic'_-: (lose sick t~= :ffrc ;:i ,;ork)

'isit your pilvs-ci- n

. s ~ - ~-: cT:er?~rc. rcc-;
p. 49

SYL = SCORE Sr-it-ET

MUP

vs.rEcr NO .

A= Exertion

DI~ID . ,~ cv C., Scale

CORING ° w w w ►-+ > ~ft

1~-i r-4 1-+ r1 F-~a c*l N 1 "'" 6q VOtL'11Y

.-~TE 20-DE~~ Ca U. E-~

U. E-1 E+ H C~•

~n U) M o f G= (n cn at all

=TRACE 30=SE o oa

i rx rz r:.~ cz ~.• a' 0. S=Ve_ , Very- 0=`^=rLD 40=~1CAP . Little

PUUM

z= Lio-ht

:Tt3SSO~~.S S

qAs-.-Ellr S l , t ~~~ 3= I~deYate

~i ~=(~c T I y L to` 5 =

r ~A-P .C.:S> 1 f ` SC~! --.Ni:aL

H~=-~y

~PMT-1=s OF BREa?S i i ` ,

1 / C75

1 LT

C~

! G= 2a-TJ

cA± D IEGLL

)OUES =I ON 7 to °- --

~~~ 1 1~, ` ~ i= 1 I 1 l C,- t ! ~c_-- I VE= r-

--Z~,~ 1 I L 1 1 ~~ ! I I~ ; ;~ l (

i'

/

J=~ Verv, V~-~r,_ ~-+

ST 1'_t=: ~~...JS/

~ f Heavy

t

~~~,~:~~ -~~.,

► ~ ! 1 I► _ 1 ! , f , , ~ ; ~.

- iCti

AI~" (00)

sy=tcros F~ disc=ort ~ ) f

s ted several hours

:he,7 cause you, uld t to

f,t

Decrease optional or recreational activity Lis t

Ta_ke additional medication

Be unable to preform the me--im. n =rnmt of work that you could normally perform

'IL=, this workload level ao~-Hdisregard fatizue )

Be ~.ab1e to perform your usual work activity or level of productivity

(* occ:.mation, sc,-cchvcr'.ti, critic-al household duties)

S ta v at hc.-m:e sick, (lose sick ti=- frcm U-ork)

Visit your pnysic- .

~isi ~ =.arbe^cy --ccm
- p . .5 .Q .;

SY`~i Pi ri'Dl`1 SCORE Sr1EET

JROUP

SUBJECT NO . 33 B

)ATE Exertion

:OrID .

°

r-i N r) Scale

;COR ING w w w w H~

°1WtIE 20=%-DDERATE

cr~ cHn

at all

i=TRACE 30=Sr VII'~F P4 .

°a

0 .5=Very,Very -0=.= 40=P11CAP . Little

pUGH 1= Very light

FUTUM 2= Li ght

UBSZEK?AL SORENESS

R AIlA1~ESS 1 ` ~ ~ { 3= I-bderate

ORE ?HROAT 4 to '5

D rHOARSENESS) SSomewhat

Heavy

:ORTNESS

OF BREAM 6= -Heavy

^-SaL D±s~~La.~/

7NG"r.STION 7 to 9 =

Very Heavy

10= Very, Very

-:EST TI~SS/ Heavy

=RICTION

=~~

=`'•-Da~-~' + ~ i ~

L : NO YF-S I II I ,_11 {

~ S~ =1 NS

{ 1 i

TS-7)

)RG EXERTlov

'ALE (0-10 )

symptoms & discomfort

.sted several hours

:ild they cause you to

+~+

Decrease optiona! or recreational activity Lis t

Take additional medication

Be urZble to preform the IraYiirnmi arotmt of work that you could normally perform

Turn this workload level c.m isre,-ard fatigue)

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

(- occupation, sc::oolwork, critical household duties )

Stay at home sick (lose sick time from work)

Visit your phys ic f:n

visl~ roc""'
p.51

S][11TC11i SCORE S'r .T

:TB .]ECT No .

J-0-9 9

Borg

01 Exex-tion

)ND .

o ~-t c"I M Scale

.VR11`RZ

~ F~-+ ~ M =N--ONE 20=~7DII~ATE U.

CV 1--4 =~1o th'ng

v

p

] ~En M cn O L-= ci] M at a1 =MA-CE 30=Sr:V~'cE w ~

40=T-,NC.AP . f I 0. 5 =Very, Verv

Little

,~~ jl=Verylitht

I ~ ~ ~ I

;_~; t 1 I 12= Lignt BSTEPHAL SORF~. Ii ESS

ASdA~i ESS

• l ~t 3= Nitderate

E

z- ~~~(S) i i L to;5 -

~ ~ I ( ~ t~ ~ I l SC~vZat

Heavy :)R=S OF BREATH I I

EAT DISC-T-=-E/ ' t

9 1~~~~~0) I6=v~vy

t

~=rSi70N ' 57to9=

4e_y re ,-

~'~ 1~ JI ~ i,• I I I I~ I~~>>! i I~ 10= very , r ~~T ~Y_ ST TI-1! IESS/_ Heavy

-TFLTG1ION

I

C-tiT E

_ .~rr i

l xu 1 0

: M

_ LLC _=__! UV ! I I

_ s~~vs

~1) I t I ~ `.

iE (0- 1 0) ~2,

symptoms & discomfort

:red several hours ,

d they cause you to (00~' t"tt t

i

OOQQOQ. ,,

{ D

Decrease optional or recreational activity Lis t

Tak.e additional medication

Be unable to preform the ms`- izr,+ m =cunt of w~rk that you could normally perform

Ttjrn this workload level vc (aisregard fatigue)

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

'1" occupation, - sc?wolwork, critical house_hold duties)

at home sic'_c (lose sick t~~ from wor?~c)

vour phys ic ~-i

ffr.eroe_^.c'7 roc~?1 ; ~ ~ ,~~ +

~ ~ ~ ~ ~ i
p. 52

SY~'i IP'lUUM SCORE Sri E

M,UP

vB.-r NO . _1G

Borg ATE

Exertion

ONID

. u: N r~ Scale

MRIlNG ° w w w a.~ 2 cn W cn

~ANE 20~DII~A'TE P14 rni v'~ v N H `'' 0 O=NO

~ o~' i w M m at a~llg =TRACE 30=SEVERE ln:~ o 0

P-. a a

3=I- LLD 40=INCAP . 0.5=Very,Very

Little

)UGH > >I~ ~I I ~I~I~, ; ;.

,~,~ 1= Very light

2= Light JBS'IER.Ij.AL SORENESS

AIdAMNESS

3= Nbderate

►RE THROAT 1 I

,rHOARSENESS) 4 to 5 =So=NIh at

nxTNEsS OF BRFaTH xeaVy

SAI. DISCHARGE/

1 6=Le?w

NGFSTION

7 to9 =

Very Heavy EEZI~itG {

1 I t I , ( I~,'' l ~ I I~ 110= Verv Ver-;

EST TIGITI'NESS/

Heavy

,

STRICTION "

IIG rE

.~DAQIE

DNTAL : M YES { II I r ~~;I I ,

-%1-.1 J 11"lt 1VNS ~ I I 1 '

-ST)

! II j !

ZG E=TION 1

J-E (0-10 )

symDtoms & discomfort

3 ted several ho urs,

1d they cause you to

-F ,

Decrease optional or recreational activity List

Take additional medication

Be unable to preform the ma.~inu~i amunt of work that you could normally perform

Turn this workload level c,-r. aisre1-ard fatigue)

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

occupation, schoolwork, critical house-hold duties )

St--ay at home sick (lose sick tip-.e from work)

V

d~ i -

isit your physician

;sit an E:-r.er~ency re=1 ~
p. 53

WIJr v'-'~1`

I 1

IBJEG`T NO . J099 ss,

Bo

rg

Exertion

fiID . ,~ Scale

X7RINC ~ ~; twn

►-+ r-t f-+ cv s-A cn 0,-Nothing VZ?NE 2Q=`~SDDF~ATE ~, U.

H ~i~ c~n v ci~ at a1

7~2P_CE 30=Sc N. a a a ° °w

0 .5=Very,Very *`^ T_.L.D 40=T-tNCAP . Little

RM C -, ~ ~ ~ 1 ~ 1= Very liant

z= Lig .t

BS MPI.IAL sox=S

a1vA~IESS ~ ( ~ { l ~ 3= 'Mcderaze

RE TfIRQAS C_ to:5 -

= In~sa"Tatz

j> NP-MIT

OR=S OF BRF4Tti 1; 01 C-S 16= Ueavy

S a?DISMARGc:/

/ to 9 =

-r T

~e ;r r_~

7

LN G

L±o=very,very

:ST TIC11 ~S/ Ee-avy

=CI`TON ~( I ;, ;

W ct ~~c ~~! ' d ; 1

~NLA-L :~ Y-FIZ

ER~I T,_~OIN

:ET)

::F (0-~0 )

sy=toms & discomfort

:red several hours, O I, I

drthey cause you to C

I

~ t--~

Decrease optional or recreational activity Lis t

Take additional medication

Be unable to preform the ma-d. m+ m aintmt of work t_'zat you could no=lly perform

Turn this w-or?-cload level -n (aisre~ard fatigue )

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

occunation, - schoolwork, critica-,! household dut l tic -J'as )

at home sick (lose sick time from work)

vour pnysic~z

Em.eroe_^.c,r room J^, ~

6 ! i

~
p. 54

SYMPT101A SCOP° S'Ci :'.t

. . .'• ~~ ~

N{Vr

[TB.IEGT MD . 10 K Borg

ATE Exertion

O1~ID . o r+ ~, ~, Scale

ORMIG t!] cwls ~

NONE 20~DII~ATE a; vv ~ v '-' U.

EA 14 El P E'

c~, ►-+ c-~ ~~~ 0--Nothing

at all

=TRACE 30=SEVERE N

w w w _

Very,Very ?~IS) 40=INCAP .

0

.5- Little

)UC H 1= Very light

2= Light

JBS7 ERIj.AL SORENESS

AIdAIUMSS 3= Moderate

1 R E THROAT 1 t I 4 to 5 =

T HOARSENESS) Sonslat

Heavy

:ORINESS OF BREATH I I ~ FJ ~

` 1 1 !~I ~ ~ ! +~'Sl I -516= Heavy

EAI, DISCHARGE/

NGESTION " + 7 to 9 =

Very He:-W:vy

r',,'✓ , 11VV

I, 110= Very, Ver_ ;

EST TIQ3'INESS/ Heavy

STRICTION

TIGUE

AD-ACHE

DNrAL : NO YEs

E IRRITATION

HER SYMPTnNS

ST)

ZG EXERTION

VLE (0-10) i

synmptoms & discomfort

;ted several hours,

1d they - cause you t o

. --,

Decrease optional or recreational activity Lis t

Take additional medication

Be unable to preform the maximum arount of work that you could normally perform

Turn this workload level wT. isregard fatigue)

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

V occupation, schoolwork, critical household duties)

Sway a w home sick (lose sick from ~•~rk)

Visit your physician --~ / Visit an emergency rccTl
. U w w ., r, •,.

° .. z o a p

. 55

..

W w

. .,

.. . w o H

id . . ;:f an . 7 w A

A...' .~ o] t~ PG U W ¢ a N ❑ .~ ~ H z H N ~/

~ O W~ A d ~ H U U U O~ N ~ ~ (F7

' ~?~ O~ k. O D U H H C.7 W .] PG d Z ~+ W C>PG (.> PG ~+

p, H N O W l] x A A O P. H N p; O

] !"~`. cn O W A C~ C~ H H >G O a >L ~4 W~ W P4 W H H

a w~¢~ ota~ H

H{,~ t{,n.~ N

(..~ o zU ~ a t~+] ar~ H w

n U U N W A H N N ;IQ 3 PG w' 3 H O N FL 3 C~c1 tA a x k+

31

_ ~ ~

W en

. .

7-

.cV ¢ N N

m w a 1111G (> 4 . -1 H N PL ~ ~ ~aN H

a w t~' w w O.-1 N w

:..a cO W > A. 7C H¢~ W W .-~ .

.a W ¢ O

pq w p, 2 H P+ H H W O O N

04 co &

0

H ~ W A O N

A

.Z > N > U CQ O co

U

. . .

.~ H t=] U W W W P.' 0 ?G

A W C7 WO[~ 60 [OC~ tG,.~ H U A+ WW

W ~ N O [Qpi 0

0 U W n: aG PG w' 05 fx w' nG O u~ O 5C W H H O kpW,.

cn C~ U w' A C. A I~ A t.. A ~. :Z /~ aC ~ ~ ~ U d

f~7t7~U~a 9 r 2

N S 7 /t i, It t -

1, 1,7 i <>>t t sY >; u~l ~S f, 4 ! 7L 3t i'i ic f ~3 4t wt V> l u VS <<J1 4 ' t

OG w N U)

N

Z

pq

w x >t ~ ~

P 4

o

~ tn W 0 H H ~ ¢ W x ¢

O H O¢ w' H w E

n

N(,.~~ 0 0 H ~ x ~

- • W ~ H P: W w' x1 ~ N Z H N f-H

U-4 r), cq

'n CLI o ~ ~ 0 ~0 0

En Ln U) __1

WEEK PRIOR

ON CiITRY S ON ENTRY

114 Clu\14BER IN CHAMBER

ON EXITII4G ONEXITING

1 HOUR POST 1 HOUR POST

2 HOUR POST

A

2 HOUR POST

- --

3 HOUR POST 9 i 3 HOUR POST

DAY POST I 0- DAY POST

WEEK POST IdEEK POST
p.~~

/ 6)-~h ~

C

F- C C ND

C ~ -

s c o = _ ~c ~p. 02~~ z ` ~: ~ k G < <

G - _ ~

u: e

La= Al- . D Lo= --,F c ;_2 .

c 0 Uc-_

S?U'" rivS~~S~ E'-3Y L S

OF, 1~ I~ 4 ~ I 1 1 ~ I ~~

S OEE

( or EO°S -c YLS S

S EOR Ess /L

/0 (~1 ~ lIJ /j' l

Z , NCI z

z=S :~=C^~~_v __

- ~ ~ .

-•~ ~ ~ -: _ .r ._

= ~ o~:

H1i V

~/ HJ i

s :Z3 octs ~ disc_ z_o. :. t

e= s e-r e r 12- ho u= s, --- ~. .

.... ~-~ -~

id. t -'- e .r cause yeu to :

cer tc ~-c )

~ Dec :-e_se oo ci onzl or rec___~=oa=? ac --; -r i-z-r G

~ Ta ;e aca? t i ona L me•.i_cst*_o n

Be unaole to me-for= tae a=ou^t of v or'c tclac you ccu_c

~ -

per-for m

p

Tura ti'_s G"Or~l OaQ QO v a ` O.=sr°~a_ : t '1 e )

Be L11?.O L _ t0 DZ= 'O r l.VOllr 115 :1 --, aC t

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to A-? )

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Tal'-e additional medicatio n

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perform

. Turn this workload level doG;l(disregard istigue )

Be unable -to oeriorm your usual vor'.j activ_tf or 1e,rel oi productivit .r

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p.60

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occupa t ion, sc~ool or~, c-'_ i c__ hcuse^o 1c

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p. 61

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Take additional nedicatio n

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perform

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tay at ho~e sic_ose s :c~: ti 'M e Iroc, w or'`)y

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p. 64

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p.66

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HER SYMPTOM S

(L I ST)

-=toms & disccm_or .t

= d several hours ,

they- cause you to :

_~- to .4-R )

Decrease optional or r e cre a tional activity List

Take additional medicatio n

Be unable to perform the maximum amount of work that vou could nor-~allY

perfor m

Turn t h is workload level down(disregard fatigue )

Be unable to perform your usual work` activity or level o' producti I ri t r

o c c u o a z 1 o n, school,.: o_T- .t , critical household duties )

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ter cause YOU. to :

to :A -

)ecrease eotionz l or recr°~tiona? zct ; ritr i,_s t

- z ;-; e addi t ~oaa1 ated. i c a tio n

3e unable to re=-_orm the z m ouat o= ::o--k- that :rou cou?~ r_or -a >>e

~erioru

'ar 7, this G-Or':I 0 2G dc ; ( Q15re ga :Q LL? ~

11n20 L _ to be='_oryVCu= usual ..r o r ~: l SC v_ r= r o 1_•r°1 p : Cr GllCL r -r

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p. 68

, . .

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GROUP --

.. 2

SUBJECT N0 .

DATE o G Ar24~,

E ca c

.:,

COND . C~L

°

rz r~ ,~~ z ° z z

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cc

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f

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SUBSTERNAL SORENESS

(

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J

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~Q 'l ~ I /~

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REST F

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FATiCJE ( ~ ~ J ( ( f ~ ~ ~ +

HEADACHE

`(IP5 I (

J

FRONT=L : NO YES

EYE IRRITATION ~ ~ ~

OTHER SYMPTOMS

L T ST I

= sym_toms & discomfort

asted several hours,

-w ould they cause you to : Refer to a,-g )

A . Decrease oD ional or recreational activity List

B . Take additional medicatio n

C . Be unable to rerform the maximum am ount o f work that you could normay

per*orm

J . Turn t h is workload leve l dc w ._(d~sre ~_, ) .~~-~. _=~ae

Se ~--,_i i e t per_ cr-., rou : u a .:o : -: a C ~ -_- - e c : :c-

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p. 69

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:

tn a~ you could

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un to A r., A A ~A I+ z/~ x~ ~ ~ U ka ¢ ~

21 \1

r / - c >r l~ li rt ~i 7f 7' 1i7 7t JI7_2 ~' i~ "'+ 4r 4i (I Ty VS r l 4/ 4 ~ ri: y S1 LI y

x w cn c~i] W x a~ ~ oz

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w rwa w t

C) w x ¢ H

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W 1-1

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r w a f~+c w~wx

Ir

Z

A • '"~ . N H 6 r-1 p{~;

~D A U W W C~ i, r. w cn H

~ ~ p,' ~ W W~ cn W O ~ ~ G O O ~

N cn C~ U rs

W

. cn 6 J U cn cn cn cn cn p; :3: u W O

m b T T~ Ej WEEK PRIOR

ON ENTRY 4 - -I -~ ~ ON ENTRY

- - - 4 - - - '' ~ -I -- ---~ -~ - - T IN CHAMBER !

--- 5 - - - -~ - -~ `~ - --~ -` -~ -I - - - I N CHAMBER ~~~~ SZz

ON EXITIfyG _ 6 __ON EXIT-114G

1 HOUR POST _- -- -- I -- 1 HOUR POST

2 HOUR POST E- 2 HOUR POST

-3 HOUR POST_

--

9 3 HOUR PO S T

- -- - - -~- -~- -I- -,- - -i- ~r f DA Y POST-!_ 1 0 U 1~ i ~ -I L-~ ~-15 ~ DAY POST

IJEE K POST---- D _IJEEK POST

- - -L- -~-I -1- -I~- -~_ -- - - -
~ p.71

00

,~ -- _

GROUP ~7

SUBJECT NO .

DATE -3 -~-~~j

E" H y t

r4

~"+ ; z z

H

COND .

c F a h; f-7 O f=: L=I Gri H F-! F

C!] U]

.: Q <

SCORING X t- a ,.. .

f1.

!=NONE

~ = o _ a E- E- a E z F, E20=MODERATE ~ E U v U ~ C

C-1 S=TRAC .. 30=SGvE,:E c; a: • c r4 : ui w m o w CC

10=MILD L0=7NCAP . u~ w x w ~ c--x ~ a aa., ° a u:

COUGH 20 ~ d lQ ~ D t G I v ((~ U ~j ~ 1,D

SPUTUM

SiJBSTERNAL SORENES S

OR AWARENESS Lg 5 ~ Z-o ~ 9-4z) llczSORE THROAT

o r. - ' S E. ES 3 5~ .S ~ 1o lo 1-/b 1161 t G ~ ► ,

SHORTNESS OF BREATH lQ 1~ ~U 1

6 / O lO ~O

1

0

NASAL D i SC ::S_ ;GE,;

C

CONGESTION 2~ ~ d (D 16) C O 16) f~ (G ~ lb L c)

W EEEZING °Lp ~Q ~b l U )' o

CH-EST T_Gd"vr~SS i

RESmR1CTI0N ~d lC~ ~b l b ( 0

(~ to f1,0 70 Zv 7-10 ~-~

FATTG r= l0 5 5 ~ ~ lU (O /L 'O

HEADACH

E FRONTAL : NO YE

IRRITATIO N S EYE

OTHER SYMPTOMS

(LIST)

~ symotcros & d :=_ccmior .t

asted several hours,

Duld they cause you to :

=eier to ?.- a )

~ . Decrease onzional or recreational activity Lisz

3 . Take additional medicatio n

C . Be unable to oer :orm the maximum amount of work that you could normally

perform

0 . Tsr._ t' s w .. _ :~ l oaci level dovn( disregard faz_l~ae )

Be unabl e to er=or. . . your usual act_-r'_ - -r or 'e' c~ productivitr

(* occuDati .,n, -schoolwork, critical house'-o Id duties )

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

`1_s_ rour C--a
V

~- C ~~ ~ ~ V V' V r_- ^

L~

_ VC ~ z G7 ,' C

) N E o=MoDE ^^~ cr, 0

~= U C :~C : 30=ScVr~L = E U C C!I C=

C= E c

_ c `~ L ~

-LD 4 0= 7i1C~°

. co

c C.

-- a. a- cl Co ~ O

w~-- J-~`~l ? I

,I_ ~5~.. . SOR ENLSS 4~~ e

; ~ E'llf Es j ~ ~/~ 5 5 5 5 S 5 tL~TLROeT ~

F}opDs E N E ss) I 1 ~ ~~ ~a (O C~ ~~ 2m

~'~i-o ~ scs s_~cL /

ON

1/0 ~o f~ ~ o ~c (4 ~D (o ~U l G

ITro__TN LS S

'-cm r 0y S ~ ~ (~ 10 (a ~a (a ~~ 20 ~

NO

I T?_'T 10 N ~ 5 S 5Ts ~

JT s ~upTO M S

;T )

D ms- Sc Q~sCOf7SC ~ /

°ve : al 'nour s

2Y, cause ycu to :

'A-E )

r ease oDtiona'_ or recreational activitv List

e additional 7.edicatio n

unable to perform t h e maximum amount of work that vou could normallI

-form +

a th is Llor ~cl oaG 1eYel Qovn ( Qlsre c-a : a iatlvue )

~

unable to perform vour usua ! w"or_ti act i 'r i t v or level of DrCauCtlv' D r

c ccuDation, sc :001 or~, critical household dut :es )

'r at hole sic=-!lose sick ti te from :.-or :~)v

't Your, pGys-_' :-'a n

_ :'Con
p.73

~~ ._ _

i

GROUP ~ ~ ~~

::~

SUBJECT NO ._ J=! (L

DATE o

z z

COND . a r H F~ ,H_ z ~z ~ ~

H w O w u w H r~ ,*

~a '_ ~

SCORING a ~ z CO CO H co F ..,

1=NONE 20="fODERATE co E U ~H H H H W ,•:.~ U U U `.C O .

. . CG E- !z E~ !L E Z U H E

S=TRACE 30=SF,VE:E w w C w rn w CQ w

co

o

10=MILD ZO=INCP_P . ~~ a ~ ~ w a w a G, a o o

COUGH

SPUTUM l o 1

S 0 SUBSTERNAL SORENES

OR AWARENESS LD (G

SORE THROA ( or V C AD S L

T

:~E S S )

/ C C

S, 5 ~ C b, l o ( v t

o

SHORTNESS OF BREATH IO_

NASAL DISCHARGE /

CONGESTION ~ 5 5 ~ S 5 5 ~ 5 5 5

WHEEZI N G

CHEST "_'IG H Tti 7 SS /

1 5 5 5 ~

RESTRICTION ( v lo f 6 ~~ ZG 2U `~C~ ZC

FATIGU E

HEADACHE

FRONTAL : NO YES

EYE IRRITATION ~ J S 5 s 5

OTHER SYMPTOM S

(LIST)

symptoms & discomfort

=asted several hours,

~ould they cause you to :

=eier to ^.- H )

A . Decrease oo-~;ional or recreational activity List

B . Take additional medicatio n

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

perfor m

J . Turn this -workload level dowP_(Qis"eo^2rQ fatigue )

F . Be unable to per :o=i your usua l work* acti-vi-:;f or level of productivity

occuDat'_on, scnoolwcrk, crttical househo id duties )

St a, ,a-t home sick'--se si ck time from work

V our
' ~ U"S ~;_ c= :~~ __/Dy"~ h G~xY

D A-= Z

COND .

IX

1=TOtIE 20='rn~~~"r~ c

C 30 s L:va ~

L0='i_~D `n - • o ~ X }~ ^, ~^X x ~

C12

-- • _ ,_. c_: z ^.- z ~ r

.' ^.

. ^ c ^

. . ~ -

COUC= 1 ~o l~

C) I

~G c~, c~ La LG

J 2U`?'UY 1v ~ v ( o ~ o~ o i o ~o ~a

i

c

SU~S Lz'ir j o i

J

OR ^-_=N . SS

~G I Coj '~ ( CD ! r-)

SORE mi E:-i Q

.n-_`n

(or ffOP_°Sr YcSS )

lv ( ~ (V l ~\I ! o ~ ~ LG~ ~O ~C) c(~ jC5 1 l..

~ JG-OR^~Y,SS 0 ~ 7 1 0 1 0

~1Sr'_L• !~!~v LL s~C J /

C o qc- -,ST -I ON s 5~ 5 S S~ s S 5- 5

Z _ N G

-

C

, n.~R~ .~SC

LO `LQ Lc:

o t-°~= yo _ ~

-_a~ ~ 5 S~ 5 5~ 5~ S ~

-~mr--, •~_ r. .n .`,(C N`~-`J

~z~ se re-'~ ~ hou- s

(Z =use reu to :

=' tJ S - C )

oDtlOnZ l or rec_°_tionai activit•r L ;St

2 Ta ;e add' t ioa a ' medic a tio n

_

'B e uIIZO i e to OZ=fora the Maximum amount a : ,/-(:)u cou-, Q

p ? - : O L'

T'- _ z t :1=s G-OL- '-- -I 03 d l e 're l. Q0 v 1 ( Q :sre g 3rQ L3t1 ~;,1e )

= Be una'oie to pe~ , your usuz _ i ror',

i acti r t r or 1e re? oi n :cduct~~rit

occ u oation, sc l: ool ::or k , c ;-'_tics l house :o 1c du" ;---s )

= S --a r a~ noc° sic :-,(lose s'-c~_ time II ~^ m

V

= `r c u_ ~ . _ _ .. . -3 :.
p.75

D ^.'" 'J 2 / I

CC ND . C

C " - - -

1-= Z ~ ~- _

S i. J ~ ~ iTC- 4G~Q . o`~~e ~ _ z 'c~ C !•~ ~- ~ ` ,- < <

7=_ 30=ScrL3

=N

--a n0 a

C

r..' 2 0 =2£ 0 D = C U

: - ~ ~ _ - C!1

L ~J ='_7 ~. D 40= _ _~I C ~ ° .

a_: xcn

COUGH

s Is s ~ 5

U l l J/

5

/

S C7U`LT~7}/

Is ~IS-15 ` ~

Su3STE.',N!L SO~~; v Y'S S

SV

O

(or SOA°SL

F,

R7

a:,

T

z3E

ER Q_"-_`T

.1ESS

:TLSJ

`

)

I ~

5 lio ~ 1c) l~ (6110 116 11 o

ScGR"=IrSJ OF n 7 7 n~_

~ ~0 (v /0 ~J O d l~~

NA-Sr-I . D ESC E-S3C E /

COKCEST70Y S S S ~ 5 S

~~ ~ ~ J

V ~ a c- ~ s S~ S s S s is

G4SS T _-r_ .,T1N /

^J J

7=C T_ ! 0 _y 5 S O

= 7'7

= lU

- e~ =~ =~_m G~~ 5 S S 5 S IS 5 IS ~

~^~' ;? S •_ ~.r~r, ., ~i~ ~ cl,ZZ,~.

-- _~~•.,,

ss- ~toas & discom=o

Z e^_, Se'rer a i hour s

d the .r c_use you t

A -3 o _ er to )

Decrease oetlonzl or recreational acti-rit-r L - ;

~ La-%e additional me-4icatio n

, Be unable to per :or2 the mz. .ciyum amount o : Gor!, that •rou could :or_a'-1I

perior :

Tur-; this c:or!~load 1e,reL doc.•a(disregard fatigue )

Be unable to Cer :oru your usual ~rorz1 acti•rit,r or 1ev>> o~ ,r.0 ti ritT

occuDazion , sc :o01-. or!c, critical inouse^o 1a du ies )

= Star at hoc~ s~c .:('ose s_c~: troci

v

z

_ ,roCr C r~'_c L_1
p. 76

, I~ ~ !` {~~~ { •~ . ~ ^ i

A

Sv ,-: = . . :tG .i_~

fI71L

C

~! ^ =

FD

✓

) /

r' ~ C ^- f^ ~

S i. 0 a _?.C Ul c:

-= ~- r

!

< c y

5 _'_R : C4 :a=Sr: t -E ? -

^

C

tG-' 77. D L: p= 7 i

JC'= .

~ -~ - = ! - =_ '= f =

>

`_ ~-•' - = ! -- _ -

_

C 0Ue= 1 to

S

S UTli V- IS 5

Su0 : ST~"i'_~• S0~ =`.T~SC ~ ~

3 0T G n

n

or fio?'sc :CLSS } S s S 1 Q to ( d 1 C~ 10 (o (,o CC'

I I f

(

,0

:~Sr;.

: OtzG =.S'?`=0Y LC) - _ ~

2U

-

c ~rn Y 10 ~ C) I Io j~ ly ~o l U U O~~ 2 f2l G

__-

,

:O ?TO

== ? S': :f= 0?~r5

zz '•"

i

4 ~3 as •.. .LL : V' i -

se*re i-a1 hours ,

r

t :e

t z) A-

:r c=use ycu to

;-T )

: ---

Dec=_ase ootiana? or r°c__~t :ona? actirit_ Gi_t

Ta :a- e additional ne•a :cat io a

Be unable t o De- for

m

the aa -, ; = u m a - ouai. o : GJr'.

; ha you cCU lc

Der :or:

Tura t :'_S G:OZ' ~: 1avG L

'_

.r° !

Be l1n a. 01 2 t J Dz :•0 ;'~ . rOu= l1sII.a1 =or'~ 4 act--r- ;Or 1_ ,r -~1 Oi PC C

ri f

( oc__ 0 a Z: _ c ,,, so'_-oc_-~i_a L hous_cc l c~ _

Sts ;r a :o s----,~os e sc -_

V_s_ Vour ~ __ __ . .

v-' --- - -
p. 77

~~ ~

(/

y ~

C. 'v lY D

1=~,.T oNEW 20='_snD=~= °'' C=

~C4 30=~ c:rZ°~

io=:r_:• D x a=_ NC A-'2 ~4

c 0 U G- 5~5 S S S 5 5~~ 5~ 5

SPU"_'iJL

"

SU'STEaXAL SORENES S

0 a a:, E.z=-S s

`0 l6 /D /rj ~G

SOR7 i=72 Q d m

\O Z' ffGl111SC. IN L.SJ C U Ito 1/0 fU ~C (G 2-c-)

OF BRE-1 R= l~ !o jD 1/0 10110 `U ~U 0

Y1SA r . D : cC=s=-c 7 j

~~ NC-_ S T _GY 55 S S~ S~~ 5

~ 1 r ~l

C,-_v ~s~ :.- 7-S ~ -~r

~ S ~~ ~ ~D (O to lo ~ CJ j~J ~C~

1 - - - ---

.~~

, ----------- -

z_ 7 T !m a : ly lo !6 1 C-)

jo ~6 w t a~y ~Q

-r--ST)

{ _ -- .

L/_

~2= Sz

=Q t7eY cause

-re : ~? n Otl

Y--ou to

; 5~

:

. ~

to a - T)

Decrease ca-faa a

.~ T3i

• ~

e additional me•.1=c M :; !ol1

~ 1 1 f

- B e unable t.7 D e~- i o L m the W ? ~'~llIB Z.-:ou n t of i: J :' 1i i. .78 ~ 'rOu Coul d

Per ior=

Tura t ;: i s 4or~loac leve_ douz(d_sre~ar~ fat'zue) ' oroclc

= Be unable to oe~'o :a you:- us-,I--! uor`.t` act _'~r=t, or 1e,re_ o f

( j OCC'1J at LoCl c-_ .

.Lc3'_ t1Cus Z~ ^-o

- .C.~.a% at ho z e 5 i .- :OS e sc :: i':C. %o

S _ .. VC U ~ C:rs

._=:7
~ ~

p. 78

.

7 7

D ~_^f ~ ~ 2: h-bl

, = - T =

Co K:D .

• C _ ~•

<

5 COR __YC P- ~~ z m ~; r- ?c < _

1 = NO NE 2 C ='•r C D "_ T

~ 0 ~ =~c 1 r aZ ^ C_ C E r- ~ z ` _ =r

5 _=a __C 3 . ,. ` ^•- ~- '^ ~.: C1] C ~ '^ - 10-`r7 jD X

COU~~ (C) 1 /o 16 1y to 16~1 1 ;' ; ; (o o

S2JmUY- Co

to f`0

r

0 1 /G lU lG (0

Su3 S~~E'lY `L S0 ;E :7 -Z' SC

2 - 6 2 - C ) o

O R AY ``Zo Zo

SORE ii;;Cn m

(or EoP_31Sc,vL.SS ~ 5 5 ly 1o I ~p to

S e G ft'° '"_~IES J 0-7 fl c. =~_ ~= ( ~ l ~ CQ ~~ (D q~-o -)--C, iso

NAS A. D 7 SC = ?~G 7 /

CY S S ~ l~ (~ ~y Z~ 10 (61(o ( C)

~~ ..~! NC ~ \ ~ l~ lU fv lv /Q ~O ~

I - ~

! :.--_TC N ~ Is S s ~S ~

^_ E' ;?

( Li5^•' ) I `

.''u^to~as &

e : se~re :=_ ll hou r =_ t

d tue_r c -=use rcu to :

> r t o s_ r) ~-_-------

Decrease oDLiCnZ ! or recreational 2.c - i v i- Li s~

mLasz additional me .i_catio a

Be unable to ce7orm tie ma mua e=ount o~ or': t :zat rou couLc

oe~ior:

Tura t :=s uor :load 1°re1 aoG .(disre2;a ;d gue)

OQUC~ir- Be unable to cer :orm vour usual uor' ac t i r_t,; or le•r_' Oi P C

~l _ occu_oatior., sc_-col•wor :r, c-_ic _ ~_ hous ,=c

Sta•r at hoc=- s_":(lcse i~o~

Vs . vou _

V
p. 79

CTX

COND . _

?= iGLIi=2G='.

.rnD =_ T~ M = c

= C = - c'- C E- C ` - "

: c c - cr c

~

_ CZ, }O=SG r -:_: az- _ a7

- « ,

(r,

-•--='!~ L0 =

7_iC A2 L=: X

10 • ~ - ~ .- , ^r. -..-

/

CGUG2

S P U`=rJ M

OR a:,~~_ .z_~ ,

SORE "E30 i,7

( or EGA°SiY~SS

1 ( ~ ~ l ~ ~ f (

Ilo

IN- ssr r. D7S c :s 7

.,

c 7

l

cc :T c ~ ~ l ~ J l 4 1 ( ( 7s T70 y

cG ;.~ _.~n~_J J

~~~_..,~ .~~_

:•f_ "'vtf~ I

S : ~~CJIIS ~ d i

2 = 5 2 '( Z •• ~ 1 ~14 i1= c ~ ~ -r~ ~/ ~~ ~- J~

L Q t :~e .r cause v:u to :

=e t o

~ Dec : ease ogt_ .,^zl or recreatzonal acti-ri z -r L;

a'~e zdditiocal me :iicat ; on ~ ^o, iiv

Sc U.IIZO l° to ne-for_ t`.e . . .a"_ .^•'1II LIIQU^L O : C Jr .

. 7? = rOl2 C .

.ll_ G

oe_iar:

~ Tura this uo

T

. 'cad 1 '_'rel do4-z (d :sre~ard i_t~u~ )

+ O" 1°•/°_ O L DL'CG'1C__'r r

Sc ll:F.-O L_ to CZr ;C r M vol1= usual Vo r-? ac t'-

(' oC= ati0, sC=Oo? :O :C t1011s_ . . ~_ Qu-

_ _ s z

Cr,

(- ' -- - ' -- ----- _ - '-_ - _,-
p. 80

~ U,

7Z -_~ o 12-

D A---T

c c z z COtiD .

SC03r- YG 13~P ~~7 C= <

., z CO Cr., x

0?`if.20 D =~ T` Cr

c m =

LO =! _Yc'_~ cc

C 0UC^

SPUTUM

Su3S^° aN_a- ;. S03-7 .7 -,, S S

0a

SO RE i_-~ 0-"-`7

(ar aO A

-

O S :,: r~ss

C OttG~S"'-O~Y

~ ..~~ lNc

-_ _-JV T . :.- a 7-C-7ny

~ 1

-_ ___~~ ~ ► ~ 1 . j~ i~' : ~ i i ~~ i ~' ~

ON A L v o

r

a

T'T_,_m! 0U

( L _ S T )

I

: : :E: : :

°_* to S,- E )

; Decrease oo•tiocal or rec :~ational zctivitr i._st

Ta l--. e additiona_ ned --"c at io n

Be unabl e to D e-'or n th e ma : ;yu:y amount o_ that rcu could r_c=-

Pe rfor =

-71 Tura this u-or't' oac l 2,rel doc :(disre rd iati z u e )

_ Be unable to L, ertor : your usual Goacti•r;_t or Le,r e _ o- 7 roc"- 7: -r-` r

(1 occ~oation, scoo~or crtical eousZ~ . . 1 cu z ies i

a

~

=-----
p.81

S U B C

D .. _ _

~ ~

bCO IT D, .

~ - - ;_ - -

1 ttO il !'.

JcZ 0 s '1 Z .-.~ `

7 T. Lp=_vC

cn

G:

cr-

:

.

c O UCS 2 CT'" ffM

'SU3 sLEavAL sG RE:r E s I I

[C a lY __ -.'I _ .: J

J

:E m~1

0_

,t m

a r- EG A-L~ ~ l DS~~v S S ,

GR^'i ES S 0 ~

-5 Ar- DIS GLL~? RGE /

_Gq~7S~*7GY Z1 I

H /() ~ 14- H

- ..,-Cr PJ

-116) 101/014-1 Z--

`~

E ~~c~yr7

.

A rr-

-C) ~ 7 Iz

1 ~

v I

. '-JT )

-C~OIIS ~ di sCCII_C :.

Several hours

C3llse you t 0

~J S. - ^

oDL1Cn2_ l or L"eC : e ? t 1on? l

Take additional me .-Ji c at io n

je una

b

l

e to oe`_orv t ae II'. :' u[Il amount oi GOr'= i,a' - •rou COll1G .^o~ . ...'''? ~

oer*or

_a t

: -

.?s Gor ~oad 1e~e1 ao~ :(c'_sre~~-~ i'~=~ue)

11nc01_ to C e _o r .,i rOU= llsil° G-oT'~t 2.C t _-r _ _ or 1 ./°1 C_ C _'C~~ '

o c c . ._,,,,, scoo L .._ .__ CC3_ CClls~ ._ . ~ - -j C :_ , _ __
U- -- Cv G p. 82

1~ r.I T (/ r~ ~/ / l

O /LV C _ Y ' `

C

1 ^, '=

-- `

0 'ff D . ? c i= ~ C c- z z

,-:

! ?~C ~ Co C

`tO~I~. 20' cOD :ER. n r, .J v;

~_~a~CL C c- 30=Su C= c

:- GO 5-- a:: cErl

~-~_ L D LO=

- ~~ 3 c

_vCc_ c , :- x ,- x ^ c= vJ x - >< .

ocrc H

3Sly:',N41 SO RE NE- S J

d:y_n-_~~~z~s s

«, 1 ER 0 `'T

HOscNESS >

_ o R`=' NE SJ O F

-J

"CSTO

Ar. D! SCu!?

N

R C --, / ~ r

=~~ 79G

~% /// l

j-C^

70

-'iyTTiJJ~

~~ f / V

~ I_C 7 -

,~- A NO Y-S l

I rT~,m ; 0 K

ER )~~= ^O,~ s

=ptoas & disccra'Cr

several hour s

. ~

t :~ey cause yo

_4- E ) u to --• -

Decrease optional or recreational activity Lis t

:ake additiona l m ed icatio n

E e unable to perform the maximum 2.IIlou*1L of Go?-!{ that vOU could nOr : a ll y

rerfor m

uru t

h is workload 1e ,r`i do w n(disregarc i a t igue )

:e unable to per f or m your usual vor .< 1 ac t ; r_t,r or 1er el of proauc t i , rit~r

OCCUDa t i O l S C ^ 0 (D Q r '.•: c r-- T, 1 c 3 1 1CLS ^C l G duties),

! a C v ._ _

'I C -

_ _ _ • -'- --- - - - ~ C
p. 83

GnOU? o2 c'~

SUBJEC T NO .~

DATE

C 0 N D .

r- ~' ~= c z z

J e' c c E- ~: '-

SCORING a

z z m m r- cn F~ '-' ~= <

x

1=dONE 20=•' 4 ODz'Rnm7 cv ~ U Co

: U •`._ U v

5=~DACE 30=SEVL : E c C

10='4 _LD L 0= VCP_° . c_ x f; x

Cr

x u

o

"' co ° ~ cn

a a a•- ~

COUG H

SPUTUM

Si13STE R .^IAr, SORENES S

OR AWARENESS

SORE THROAT Ll /(_,

^ y ~ f , l ~ , / l lr

SCO R i"VE S J OF BREAT H

V A ~~. . D-T'S C -

1 .zGE

CONGcS T =0N

wfiEE""~~v~ G

C S`P M

R

LS~iC

T7

ON

= .'_`'1GU c

_ _

:'30NACL .NO Y-

-J- : Tn41r`' ! `iCiv r (J ~/

✓ ~ J `~

CTHER ~ DmO l~{ S

1 J T '

~f

- ✓

( r I I

?Tl n z o = S & u' SC^P1_ o ,^ .t

'-s z e a se v ersi hours,

.~- - culd t7e_r cause you to :

=jr t o A-E )

Decrease out icn al. or recreational ac 'r'_tr List

Take additional medicatio n

., . Se unable t o oe" :o=, the f`X=^l 1 amount of Wor _, t : , -- you could nor :Il2 li,J

De_' :Or^1

. _

_ ._ t _5 O_C`._ _?' . .. i ,,

.:'1~, y-°--_ ---

Sc ll__? .,__ ~

. ~---_ ._ your L' p_ ._ZC '- _ C Q'

-`.OC_ .."_f a _ CllS_--

: • ' _ _ -- __ _ C _ ._ ;
p. 84

C~~

:, U s 17 4s : you

D ,-T Z

CO qD

L ` C G

SCORING

1 =`t~O A f ?:•' 2 0 ='fQ ]_~ e_r_ ^ G' ~' G: C; ~ C; L f^ •--• ~ C

- v n - 7•? = CE :0 =~ c i 1 r.~ ~_ c c f m =- - := m C c -

T- D 40= 7aiC c }r_

C OUC_

~

-

-

~

-

l 0

SPUTUM

u3s L E .°.t[' L SORENESS OR

/D

or-

'7

~o~ss :,rrLss) J

=oR~~~~~ ~

s= ~. D E SCLLAR G E / ~~)

rzc 7s T a ~'_L/

E Z _rr G 2 ~

o 16) i O

~ • ~ (

7 = 77 ~~~ ; ai: -

--~ •: ,,~_ r.,, ~fc I

L! J~' )

-=toms 3c Q1sC c .a *_Ci . t

several hour s l

L1eT cause you to :

D?C^_? sza OOLICCI? L or °C ° tiOC? } 2.c i,='r 1

.° add 1i.1 or 2= in e C? t 10C1 ~ „ _= 1 1 Y

3e unaole to oet_or a t :~e m a• u3 a m ou^_t of or ti=- cou_c C,.

a t".is- oad 1e're1 ao : :( stega_ ~

~eFu(12.01°_ to CeOt.,. •rCll: usll3' Go I'~t act. r= O r 1°•(°_ C= . JC'1C ~ 1`~ ~~

OC .. t„,. sC_.^CC_-- C_-'-C__ . 1 CILSZ2_. C:. .~_-

_ ~ - r
~~= P

.,85

I

~-

.

3

ND

.0.! YC

C ' ^

_ :t0 Li ~ 2 0 = _ . Q D z c . ~ `- ~ '- -- -- c:

~O=S LL - E , E C L ~ c = z ~' _ _ c

G7 tt1 C C-:

~ L D L 0= 7 i

f C~_ C;M: x r: x x r x ; c c~

Uc- a

J~

Um

,~~S L~aNAL SO?-EUESS n ~

lo 1/0

~7J mL~oA~ 1

- EO A- ElSL :tc.S S

/

~ ~l (

/170/0 O C~_-l E SJOF 11 Il ~ / ?UOLl/ /, lo I

3 5r!• L7! JCI. -A---.G

n

.-, ~

IGcS 'TOfiT

L

U

£ :IG 1 o /-1/0 / o Lo "FLO 1/ 0

C

V T tr_C_ '- N :SJ!

.`n4 7 Cr' iO :Y 6

G ,-E ~ ~ D ~~!I i~ ► ~~ ► l~J!~~,

,

ArD :t C 7- -

-ITC

/-

- ( 0

~

~--

'

they. cause Voll to :

to a_- F- )

)ecrease oOL1oCc L o r recreational

;a kz! additional medicatio n

3e unable to De-form the L'.~.2_L' ll[LL z a c=~ oi that •rou Cou L G Co L L y

e r toz ~

"ur t h s uo : U1c2c L '_ re1 do a(d s . :d „ )

e unable to oe--c 7m your usual o_cy ac-,_r, o . Le,r°_ CL oc r'

oc_ ~oa, =---oo'_ .:o,~:, c- ------

' ~ at O C SIC,-
p. 86

D A. ~`~~'

:OND .

' `_' '- r= < <

;CD R I'N C Vl"

^

z

t ,r -_ .' ` `.

1_tOEdE 20= ._~ODwR --T .L rr. `-= c c c; CL C c

5 -S~~CIi 3 0-~rjT\ 1JL ~ G C ~ C Ul C cr_ U1

j

__

{

1

{ 17 4 0= 7 YC A 7 ~~~ X ~" X ~ }~ ~• X r

_

0= -~- C =

O UCS

PUfiUu

STERNAL s0 R E :rE s S

r gOP_°sc. :tESs>

-IT

O

/ D l lo2o nmx~:SJ a_ a~__~_rt~ l C~ 0 l 6 D 2(~ 1 ~ l C

-SA-T. DT' s C=a

-

R- GE i

I ~ ~

xT ~ 7ST ; oN 2

0 i Jo /0 U /

/

6

~I m)

i3G I lD 16 1D /0

-7 -~~ C r, ON /O/p

~

v o

7

R 7 T Art 70 N

=7v

_ i C^t 1 fl

S

^ 7Ci/s ~ Q1s ^, :1 :C-. G

several hours ,

,her cause you to :

to A- E )

D ecre a se ootlonal or r e cre a tional activ i t-r L :s t

=ake additiollal Medicatio n

~e unable to DerTorm the maximum amoun t of G- o "~C i,1a ~•rou cou1Q nor ma llY

-perfor m

ura t ;zis Gorkload 1e ,r ei doc n(aisre g ard i at iJ ,_ .e )

Le unable to oeriorm your usual ac t l,_ or L°,r !E!! o~ c roduc t--

,r a t .o s_c ._(?c s = ~ _
I. 87

MUP

3UBJECT rIC)

)A=

~ ~ ; ; Boro

T

~1~ID .

Exertion

c q rn A Scale

3CORLVG c ~ r=3 !

~ 0 Vo '-` `'' thin~ ~ U g 20=_~DERA= ni U c E- cn ~n cn c! !~' tn cn at

3=TA-CE 30=S'."=RF. r :2 C C

LO--'-,= A0=UNCA.p 0 . 5=7e_,7, Very

Lit-~1.e

- ~ ~( I ~ ~~ I I 11= very light 1 !!

Sq 2= Lic-4-it

UBSM?i•~AT SOPENESS f i

R AS~?RqS I 3= r~ Cierate

:Lii l.,

_

! ! ! L to =

-

~z T'i°~?T

fl_A__

or .~A-RSL:`LL.JS) ~ ^

ra.~VV

r_ORs'~SS OF BRLa'T:

I~ , I 6=~J~7 Y~aL._7

j?cAL DI'SQiaT~Z/

ZNO^.STTON ( I" J I I ~ I% to ~-

i

i

c= v

er."

, ve_r;

:EST zIIQ_S/ te-avy

ES 1KI C'7LoN

:=1 C~ .,E

77-6~0

7"Cti~~~ L 'No - -----

i I 1) /

! 111

,CRG E~'=, ON

CAL.F (0-10) !i! ~ I

.~ sy=tcros & disc=or`

asted several hours,

-ou1d they caus e you to

!~!

/

Decrease optional or recreational activity List

Take additional medication

Be unable to preform the max= it of work that you could normally per~Eorm

) . 'I=- this workload level ~-n (disre~ard fati~ue )

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

ccc"mation, sc?molw-ork, critical household duties )

Stay at hcme sick (lose sick t~~ from work)

Visit pnvsician

: . Visit an ~- ~.r-encv room
p. 88

~ tt

.

~

_~~ C^ (,

L

: L L

~:L`SL . N 4 r N Sc~7 °

~LJ TC , ^

~= z cn cn cn ,~ , t ~ c*t

•, c, ~ E-- c ~ c ~- <^ t t E-- L

cr_ u ~ cn c t t,~_ cc, v: - ~- e--v

Z7-: P- ~

IQ=:= T-~='_`iC'-'. Q

.~='lE .'~i,tlc'

t t Li

(5 ~ 12 s Fumu

,`- C-R __~____ { ~ 1 ~ ► , , ~~~ ~__~ n

~r=; =~•~~.~> ~ l ! ~ ; ;~ ti ,~; ~~" ~~_•,~=_

. ~ •~ << ~~1 __- Lr

Cr J i~ r i ^ I I `1n ` _

_~-

1•:i"_`:L ~ / ~

.

.

C

o

IZ-S `=-d S eTT-Er'=? ~'ict=

N cul d tHe;r Cause you to

~ . .

aDLipTlal or ra'=_°- at_cPLll cc ziV! t;7 List___________________________________

B . Take- acc=`=cna?

C . Be Ui"vZe to pr'_TQrul t 7e 2 :r' IT ail ez-c-iSlt of Lv77r~G that you Lc-"

:ld L10=a! l`T pe=`O T_W

D . t_7is rv~r:~ccG ZEnIe! wil ~Ci~rc?~ a LaL=?T_'e )

.E . Be =--.oi.e to pe_,-=orm yet--- usuaL wz) r:: ac~--ivitcT or 1evel of product_v=t- r

ccz.-rat_cn, s~cl:v cr•- , hcLse:^o1d ucLes)

F . S L= cL i.C .'~•° S lc (ICSZ Sick ti~ f-- ^T1

VcL: .= C i: iS-_, -
• /._. ~ ~~- \( `_/ _ -----~ ---- ------ i

.89

MOL~~

?.i.►

= Borg

.TEcT M .

MNID .

r

~, Scale

SCORT~I(•' t

w

n n

_-~r E zo=!EDERa"' ~ U a C5 o Vot:`1inz

t-~ a E- F E5=7-R?C E 30=SFT~~, X:

a oc. pc..,

ac ;;I I

LO=' 40=L,\ CaP . 0 . 5Very y

:OvM

1Li1=±~nt ;pulul _ f ! I i 1 I ► ~ I ~! ~! I ;_~~ I~ I 1 I! Z= ~~~- t

iU~S + r ~.T•~AT St7R`L.~.,J , I

~ 1 R pS,;a~Ecc

3= 1--l-der-ate

;lJ~y Lr'_~l.'r_~ ! I L` to -, 5 =

/ ( J1 I liLi•1~~r~

i-~t:Rr~1I"S OF BFc~~ : I I i , L~`"^~y ~ C ~

~! v I

I ~ 15,,,

~"SAL D'

j 7 t~ ao . =

-- V e=E=7 ._._v

I ~~ ~ / I l, / I j I I I ~ I

T-2, I-

~ - r r-

_o- ~=~ -~ v~ ~.

o

~ I , , ► ,

_!l.-_~

r

,

I

=

-~.~-~_,_cti ,, •, ; : ~, ,~~ /

i 7 1 l! I/,;, I I ~ j

_=

{

_`

~~ = ~ ~~_G~1 •-, ~ „ , , , ~ (o-?o)

= sy=tcros & disc-cinfort

as ted seve_,-al h=_ S

you to, culd they cause

-

. / • r, - -

. Decrease optional or recreational activi ty Lis-

. Take additional T-,d; cation

. Be unable to preTo= the =--:in= it of work that you could normally per=o=

. T", this workload level ao-W (n sreQard fati~se)

. Be unable to pe

rfcrm yo

"

usual wark activity or level of productivity

occ•roat~ on, sc~.col~vor~c, cr4

.tical. household duties)

Stay at hcme sic?{ (lose sick t, from work)

Visit Your physic~.n

Visit an rc=
9,0

MIL`LP

sUE.:~~ ~"G

/ ---bCC , (_ r_, a

CUL uJ . ~ C^ I I 2 G `'~Cr`=Ci:

. C 2J t t.y r- N c) ,

..' Sc e

SGCRT-,\'G - F- =

N H- ^' E.~ . 1 < ^ 6%~

G=T'~~("= :- ^ C: L I CI] F^ CC._ C,~ = rL` cr, ^

X: cn al l

~

cr,

10-d ' LQ_,?C~P_ ~' t 0

.

C

=Ye_' VC.

J

COUGH

~J

m

M ( I ~ I~ 1 I i , ~= Ver' =

C

,,~`,~ _--

_:=. .,

C= --- r- ~ i L7-

]i

~

~ ~-

J

jvr -

~`•L ~ ~ I i~ i ~ ~ ~ ~

I

~, ~ -

C=.,=-__ -

!~ C_ v VE-

~

last: eta, s0IE'_"-_l liCL:=J

w culd tHey c;u e ycu to

~ = J I

4 . De=r ~s 2 op t_cnF or rec_ _...` t_cr.a1 ac tivit-,7 List

B . Take edd'_t-f cn,~__l u-pd; c:t_on

C . Be t=1e to preform Lne ==nt of worJ° that you could nor?1-- ? 1v per=o=

D . Ti _ this wGr:clcad level c.cw,-. (aisr _~-ra fat_~_e)

E . Be ==i.e to pe=-=or:n y= usual wcr:c activity or level of proauct_vitly (` cc=ar_cr., s-'-cc1~Y~r_c, c__t_c`1 ficuszcold c~ t_es)

Stay ec r=.e s_c:(lcse sic_c r---a i:-'~ F cr'c)
- j: . V ~ I . 91

Q~PUP. -

sus.rEcr r O .~05~3

DAT E Exertion

MrID .

Scale

SCORLTIG E--4 I

H r-ti H N H M 1=~or E 20 ~DFRa~ Q

C E-+ E~ rs E- E- E

o vot_hL~

~

vn cn ~ cn o, , c: a CO cn F--. at all 5=TRACE 30=SF,VFiLE Fa a w ~ F-- 1 w c~n

10='^r'~ 40=iNCAp . + 0. 5=Jery, Very

Little

COL'~i J s 5+ s- ~ ~ j ~ ~i'i ~ ✓

1=

-

~,~-> G~ 1- Very 1i211t

S

P=

2= Li

"

2ht

SI7BS~IaAT SOR=S

OR AM417 IESS t/fL13te

SvRy ir~D~T J L to5

;or ~-~OA2SEIT-SS)

~ .C~•L'~'.VL= ~

:OR-=S OF BRFAT:

Heavy

cl { ~_eav',

:~cal DI-SCHARCL/

a~vc--~oN 1 7 to

ve°

C~ C ~ =

d ~•~r" ~ LNG

~ ~ 5jLLio=ve:y,verv -:ES= T7o1±-I.ESS /

sT:~.cTToN

~~~~-L;~

aA ~_.~.,_ ".

7 RON=, 10 YF-S

_-RG E:=-,T7-0N

(0-10) 3 __= syr.ptoms & discc:niort

_;sted several hours,

-ould they cause you to

. Decrease optional or recreational activity List ~ C

Take additional medication

Be unable to preform the ma--=rnmm Lmt of work that you could normally perform

Turn this workload level n disreQard fatigue)

Be unable to perform your usual work activity or level of productiti=ity

0'- occupation, schoolwork, critical household duties)

Stvv at hcme sick (lose sick time from work)

Visit your physic ian

Vis _ ~ ~~~ ~er~er_c,r room
SCORE SdEI;T p

. 92

GROUP

SUB.JECT No .~

DATE Borg

Exertion

COND .

o ( r+ I ~, ~, ~„ Scale

SCORING Cw w w _

C14 F--4 M

1=11UNE 20=NDDERATE ; ~; ~ O=Nothing

, M

5=TRACE o at all

30=SFVII'~E ~ 124 w

10:~~ 40=INCAP . 0.5 Very,Very

Little

COUGH

5,~ S J ~~~ J I~ 1= Very light SPUTLN

2= Light

SUBSTIIzI~AL S0Ra1ESS

OR A[dARr.~'~SS 3=Moderate

SORE THROAT

(or HOARS~IESS) 4 tSomerNfiat

SIHORTNESS OF BRFA~-Z j ~ SI~

Heavy

6=veavy

~1ASAL DISCHARGE /

MNG"r.ST ION 7 to9

Very Heavy

;v"riEEZING S' s I J I J S -

S

=ST TI=NESS/

10= Very, Very

?.ESTRICTION Heavy

^aTIGLE ~ ~ i ✓

~ ~ ~ ~ ~ i ~ ~ ~ ~ 1 I ~ \J

DNTAL : ~Y7 YES

LRRITATION

D= SY`=NS I i' ~ i I

"LIST)

30RG EYERTION

:CALE (0-10) ! t~ 3 3 s I ~

& discomfor t ~ symptoms

-asted several hours,

,7ould they cause you to

* A-H1 1 ` 1 iii _ I

Decrease optional or recreational activity List A

3 . Take additional medication

~ . Be unable to preform the ma.-=n nn =ount of work that you could normally perform

D . Turn this workload level wn isreUard fati gue)

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

occupation, schoolwork, critical household duties )

Stay at home sick (lose sick tip-p- from u,or'_c)

= . Visit your physician

:. Visit an en:er~e^c % rccr~
p. 93

i'✓~~~

ccQ:~= S:_.-

~ C'cCITP

D.

c Borx

.~ ~9- -7

CvM

. c~ t 1 t~ z

1 ~ ~, t t r-4 >J Sc_?e

C

/ F- -'

~ N c*

C; Vl C/~ C!7 X t 1 d _ O

1 D~~=

c:

L=' 1 1 C7 = \CL` LT' ~' Q

F- E

Cr] (r,

~ G. 1 G.,. C t G_ v] cn ~-

~_!

0 J='/e="l

tl L;-;~

CvL~~ j1LL=veryig c

G

-z7 '=~~` I'_ Ljr-

~.__. :

CR^1_~i.~r . ~ ; , .~~^

(

===

C*

_ c

-

--Z- -

-~_ _- ---'--=-_• f f'` y i i I ~ t t ! \ i- _

-~-~ '

, OMI~~-_~=vE=,

r---- ---~--- ~ y -- - _--- , ~? C', i~~~,~ ;

r-- --- -- ; i ~ i '

7

0-

L S'y~t~uS ~`c C=SC-:~LtCr~ I ,~ i

le.~~ed- S e•~eT~ hc~:: .s, + 1 1~~ I~~ wCu1d t:e~T ca-usez ycu to

~ 1I , t t 4

A . DeL'~PaSe Gpt;GTl2lor T'eC_°.°t-Cil2! o.CtiV1L'~T Lis t

B . Take ad di iona._ . T: edic `t~cn

C . Be >manie to preTo= th t or work th.:-- you cotLld nnn'~1-ly pe' =.:raz e

D . Tun t~_is ~,-or :;._cad 10-7e! cc~ (asreg sd fat_~?e)

E . Ee =D1e to p'-_'' 'OL_il your uS-171-1 work cC'~V1tT 02' Ze,ICl or pZcdLlCti-V1C7

CC=-ac=CC', SCG_CC1Cv-Or':C, c =~-C=l ECLS2-r'-01d CL~L-eS) ( ~7

F . Ct ~T dC C--° S~C_; ~~ CSe S~CGC Te i`~ piv2' )

G . ~i' : -,c ` or~rs~c~ / ll

CI_ V= _ ~ . ° °^C'T LC cm
p. 94

~~ `

J

cR ot.1~1

SUBJECT

DATE 2D Borg

E C~ i~; CJ E`

mr tioI l

C O N D . - 0~ c 14 r1 SCale

SCOR_ ._T~IG ~

M 22

H N c+

cn

1 z~t

I=~r E 20=~DERA~ U. U. c~

a

o=vothing

Ell

C' c~n ~ ~ ~ c~'n ~0~~~ w cHn c at aI1

5=2RACE 30=SF VE~~ ¢. ° a

Cn

10=`~,D 40=I..NCAP . 0 . 5--Very , Ver y

Little

MUCH

1= Very IiQht

3p=

j2= Li2-ht

tJBS'~IiAl, SOR=-S

)R AS~A~IESS ~ ~ S, 'S 5 S S 5 , `

5 3= Ntderate

V

or

RL

M

u

ARS

-D~T 4 to 5 =

r-NT-SS) S

~ I ~ ge:-ry

nOR~.T~SS OF BRE4U;-

S= -ueavy

DISC-iAER~'/

;DNGFST+_ON to 9 =

Ver r Heavy :~~G _ i0= Very, Very

Qi-T1\-ESJ / H eavy

c=

, N~ ~ " ~~

,--~

Cl~

S~- = - ' 'i0~~~

~FtG TTO7J'

,~- (0-10 )

sy~tcros F~ discor~crt

:ste~ seve~.'a1 hcLlrs

~- ;Uld they ca-use you to

Decrease optional or recreational activity List

Take additional medication

Be Lmable to preform the ~~~rnan amount of work that you could normally perform

T=- this workload level tow~ isre gard fati,-ae)

Be •L:..-~ab1e to perform your usual work activity or level of productivity

( ccc. .mat_on, sc ; cocritical household duties)

St ; at hcme sick (lose sick tiLT)e from work)

V'_..~~ ycur -nysicLan

V i an E argenc, rocm

1 ' 'l~,-_
p. 95

S`im TUr SCORE. S'r=- T

GFDtTP

SUBJECT M . 100 t~~ Borg

MND .

r4 N Scal e

Sco t~ TG r [_" L~ + t=a ~ c:' r t t t ~

p~ C `{ H F-.~ t*~

t t Q~CL`L-'a

1=-1UYdE- 20-~D~.?T✓ ,~, vy' E- t~ U t!t~ ~

E'•+ Z, I t E.' E.'` ►~, G l_

cn cn cn c, t c; Cl) cn at

5=?~-~ 330--S:,-7E--,E C- '' pw P. Cf]

0 .5°'7er7,ve'_"y

ZQ=~-~ 17 4_!NCAF

. Li tz!

CO

UM

I Lii=±c lt

v~ M-"

LL±LLL_JLJJ ~ '~{~ f5 f

i

J2=Liht

OR.

aT L~k~_`tr,

to

(C-r-

~ii

Or BMA==

I ~

Y 71

l(~ ~- Ve ~,- _ ~j-°--

!1=:~`lL..:( i 4 t f t ~ Le= i S

__--r

- ~ • t t

31,= r_~~_U;J

L3JII±±i tiJ3. I i ;~ Lf synt-•~s & di ._ .scc~or~ . ~

~ -- -

. . . t __ .` --. . _ t . . .

i.as~°_: several hours,

t , 1

uld they caus e you to

t,t

Decrease op t4onal or recreational activi-L-7 Lis t

i . Take additional me-iication

Be umable to preform the ir~~m= =0--Lit of work that you could normally per=or,n

~ . T~~rn this w-or_`clead level down sregard fatigse )

Be i--.able to pe==orsi your usual work activity or level of productivity

( ccc-.mation, sc^_colw-ork, critical house-.o1d dut_e_s)

S trv at home sick (lose sick t~ from G orc)

V; s :-- yct:r ohysic~n

is an ~.,--e~:cy rocm

T V
p. 96

3 „~r^l~ Si.u:.r. JrE: J.

suBjEcr w .~~' a

Borg

DATE

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symptoms di scomfort

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Decrease optional or recreational activity List

Take additional medication

Be unable to preform the ma~ann~m am ount of work that you could normally perform

Turn this workload level ~ wo (aisrezgard fatigue)

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

(J occ zpation, schoolwC)r'cr~4 tical household duties)

Stay at home s ick (lose sick tiz-_- from T,,7ork)

Visit your physician

Visit an rocm
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(7- Be uaaole to Perform vou : usual vorsi acti,r~ t•: or L°•r a, of nrocucti'r'-=r

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Take addit ~ -

recreational zctivit r

oaa - medicatio n

Be unable to per_orm th e ma_cimun amount of vor : that you could ncr=ally

perior= '

D Turn this .rorkload leIrel doc:a(di sregard fatigue)

7- Be unaole to oer~or . vou : usual ~ror't

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(LIST)

~ptons & disc^~ cr.t

several hours ,

they cause you to :

r to A-r7 )

Decrease oDL1onZ l or recreational activi t -r List

Take additiona_ medicatio n

B e unable to pe :•T'ora the •[y' a. :CiIIluIIl ZCIlOu*1L of G'o*-' l~- that you could nor=ally

perform

Turn this uork?oad level do v n(disregard fatigue )

Be unable to per f- orm your usual uorkl activity or level of oroducti v it~r

occupa t ion, sc :ool erk, cr tics~ hous,^o 1d du t i e s )

St r at home

V

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