### - . . . . - -- : 

# ; : -= - - _ _ ~ - - - - - - -- ---- -~~'~-- SU3JECT 

### NO
. LOc

### ,7a-` 4kk DATE 7 lG e!5' o H H v U J c~ ~, F, ~, c~ z '-' Z z c + COND . 

### 0 3 ~"~ w a a

► -+ w o w c~ w ~, E
- .., a SCORING .13 z 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 THROA T (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 perfor m ;) . 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 roomSU t JECT N0 . L OC~~

DATE E ,i w C C 1 1 C
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 F a 10=MILD 40=INCAP . 3 X W a a X a- 2 -2 a~

. to

o 0 F=' a p a U 

### COUGH 

# U 

# r7 n a_b 

# 15-ID ~-U ttj " SPUTUM r1 I ;

# o

110 6,

~J 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 ~~-~ HEADACH E 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 : /} . ~ 

# A ~ tefer to
-

A-H) n /-~

, 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

SU tJECT NO . DATE E F' ~ z z COND . ~ 0 3 H F+ t-+ r~, W a + H W E 

### o ' a a a W H 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- . 0 W ~ ~ w ~ a E F ~ H w ~ ; W 10 =~~iILD 40=INCAP . W x ~ ; a W x x W x p-, co o c~ W c~ = a p ., a Cr COUGH 

# 120 o rw O 

# 1;_'_0
SPUTUM 

# ' 

# I l 0 

# O l 1) 

# n 2~ 0 

# / 0 SUBSTL'RNAL 

### SORENESS y ( I OR AWARENESS 

# I f > > ~ , ~ J SORE THROA T (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 

# C I v oLY J ` 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 : ~ 

# 74, 14 efer to A-H ) 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 norm ally perfor m ) . 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 roomR= l~

Sli$JECT* NO . Cl~21 0 DATE ~ 

# 6M~ F, G ; 0 0 z zt z z ~ , 3 H H H H COND . a W a H L7 Q W W W M ~ a

► - Q [ C az Z Cl~ M H C!~ H y~ ~` _ SCORING Q.. =) H H M H H H ~ '-' ~ v(J] E~ U U 0 ~ C 1=NONE 20=MODERAT E 

### 5=TRACE 30=SEVERE w a C _W M ~ M W CD o F' ~ Wx X X W X W a 40=INCAP . 3 ~ a W a W a W a o a a~ P-- 10=MIL D
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 YE S
EYE IRRITATION I I I OTHER SYMPTOM S (LIST)

_._ . ----•- ' - -- .___ ._. .. . symptoms

& discomfor .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 perfor m ) . Turn this workload level down(disregard fatigue ) Be unable to perform your usual work* activity or level of productivity ( * occupation, schoolwork, critical househo ld duties ) Stay at home sick(lose sick time from, wor' .{)v Visit your physicia n V'_si an emergency roomGitOUP 2 "

• ` ~~ SUBJECT NO
. L4 &4Fr" DATE 0 w ~ ~J E' - H o c5 z z > H H z z w w

0 H a a COND . 4 W 0 W W W H H a oc a z a H H x SCORING m CO C O 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 . W X '' x w X w X w a a o o~ 3 w a w a w x w a ~ a a, o c C

# OUGH

SPUTUM 

# j 

# v SUBSTERNAL SORENES S OR AWARENES S SORE THROAT 1 (or HOARSENESS ) , •I 1 1 -1 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 jo 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 perfor m D . Turn this workload level down(disregard fatigue ) E . Be unable to perform your usual work* activity or level of productivity (* occupation, schoolwork, critical househo ld duties ) F . Stay at home sick(lose s 4 ck time from work) G . Visit your physicia n H . Visit an emeroency roomil out each column for how you felt th previous 24 hours .



# ~ MWHAT WAS THE WORST SCORF~ FOg Z 4 W YOLT : T~ -S, ANY TI ME DURING THE WEEK -T COUGH % ~ 1=NONE : No symptom . SPUTUM 

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

# 'C5 / 0 SUBSTERNAL SORENESS 5 ~ about symptom t o 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 . OTHE R
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 E- =- ~= OND . / ~ • °1~~ o ~ `' z z ;- ~ ~ , . : • - G a h < < C 0 P, 7 NC 

### CO Co H c o
- P-• ~ t i H t f~ r r . _ U C 

### !=NONE 20 

### =MOD Cr E c~ c~ c~ c~ 

## C:

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## C = E-+ E E z F E5= T' RA CL 3 0= S c : V : . 3 ~ CO c . : m t=~ cn o 

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# ~ 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 

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### Star

### p8



# ~~
D J SUBJECT NO . DATE

2j- 

# ) 2- 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= :dONE 20=MODERATE GO F v c~ c v ~ O tz E tz E !r E z ~ 5=TRACE 30=SEVE : E c. . c w cn w cn w u~ 10= M 1LD o w cr =

40= 7 NCAP . >` H X F x w x w a a o ~ w cz w cz w cr w oc ^ a, ~, o c COUG H
SPUTU M SUBSTERNAL SOREN E SS (
- / OR AWARENES S SORE THROA

T ( or HOARSENESS )

~~
SHORT-NESS OF BREATH ~ ~ ~ r0 l^ ~ I 6 a~ N^ .SA_ D1SCfi _?GF % CONGFS'`'_OiV ~ ) ) 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 

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### d several hours , i( ( t hey 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, -critical id duties ) 1 Stay 

### at no 

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# 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 

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PUTUM

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.m T ON ) ) I ) ~ ~ ~ I ~ ' HER SY XP `^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

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### 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 :



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- :urn this crorkloa d le v el down(disr e g ard ' fatigue ) e unable to perfor m 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.T E

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### ✓ J p 15 DI ,- n O 

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3 PUTUM r I f ~ ~ / ( ; UBSTLRNA L SORENES S )R AWARENESS 1 ~ 1 ~ 1 I ;ORE THROA T or HOARSENESS )
H 

## oR T

## NESS OF BREAT H A S A L DISC3 A RCL / O 

# N G

# EST-O N 

# v ~ ~o ~" l0 5 ~o ~~ jv



# Ia
HEEZIN G
: .EST TIGHTNESS/ ~ l ~ I 1 I _ ESTRICTIO N 

# s~~~JE ~ ~ 1 ~ I t E A LACIIE

, RONT A 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 perfor m 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 .
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### -

### p . 44

u . _ , _m'-~+ • 3-~ ~ ~ C ~ ~ ^ cz z KD < 0 0 ; NG ca m 1-4 CO H ~- : 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 ~ I ~ -~ r~, x F ; x ~ x r' 7 < = ~ D L

; 0 - = y C 

### i ) UG 3 .~ f ! ( ! ~ U'"Ul u ! 3STL°NAL SORENESS ~ ~ ( I ~ l f ( AWARENESS 

### 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

~ 

# GJ : I~ l 1~ ! f r (

_ D 

## ~Cu E :T iL : NO YLS ~
IE RIT?_TIO N SY M 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 :~ erior m :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 ~ SUBj ECT NO . DATE ~ c~ z z z z e *= COND . F • a t-± w O W w W H Hi a f~ f~ Z ¢ a 

### SCORING co co H co xa• ~ I--i H H H H G: C H U U 1=NONE 20= 

### M ODERATi c~ o 5=TRACE 30=SEVERE C4 ~ w cEn co w c~n o w m 10= M ILD 40=LNCAP . ` -q x ~' x w x e a ,z o 0 Cr r a w a W cz rw r~ o a c, ., n c ~ it

) 

### COUGH «I 

# ~ SPUTU M SUBSTERNAL SORENES S OR AWARENESS ( r ~!f SORE THRCAT + l t/ ( 

### (or HOARSENESS :)



## /
SHORTNESS OF 

### BREAT H NASAL 

### DISCHARGE / CONG E STTON 1
WHEEZIN G 

### 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 :'ea 

### a r .^ _ 

### az " i^ ) o - ~ 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 

# Si TJE

# CT rZ) 

# . y~, Borg ; DATE Exertion

/ C'i~i C^ Z z ~
w , 

### [--, Scale )11( 2 

### COND . r-4 

### `'~' 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(4 i 1= Verry light SPUTUM 

# 2= Li g

# ht 

# - s'~BSZ~i~al. soR=ss DR AjiP=, TESS :€ :ate = j',In deOP .E =OAT (or HOA_RS_SS) 1 t f ~ Sos a .., -na t Heavy 31HOR_T~SS OF I 116= ti aavv I S 

# :ON 

# G ES

# T_O

# N 7 

# to Q Very Heavy HE= I11 TG 

### I~ I 1~ ~ I f I~`~' I 10= Very, Ve r y :E ST TI(3~Ii~lESS/ ~ Heavy E STRICTION ATIGUE E40 . 4- E RONTP .I, NO YES 1 t f S~ ~ 

# _ tl! ~ ~ ~T~~ ~~ . ~ .~- ~~ TA,,

# TTON T 1 

# s~TONS LIST) ORG EX=O N 

# : a .1.~ (0-10)
~ f symDtoms & 

### disc=-fort 3sted several hours ® wool :)uld th ey cause yc, l t o •~ ~~,- _~,~ i I =, ~ - --~ -
- Decrease optional or recreational activity Lis t Take additio nal 7-~e dication 3e unable to preform the ma. -,:L7 ,rn =

nunt of work that you could normally per-form 11r .1 this workload level Y~disre g ard fatigue ) unable to perform yo ur us ual w ork activity or level of productivity ocespati on, s c~

^colw =k, critical household duties ) IV at home sic k ( lose sick f--r= your physician ar : =C-- rcc: q

### S'E '_FTi H SiG REE Sir= p . 47

. ••~ + 1B.JEC'T 

### ~ E~xe~rtion 

## )

# rm . fndl ,--t c 1 l c n Scale 

### bRIN(' cwn cw M HH i I i' ~ r-1 H N F-1 Cn ~o 

### thjng 

## - WNE 20=~DERATE E--4 0R 1 : at a ll =TRACE 30=S~E ~~ ., a a

° )=`_~,D 40= 1N

(' .AP . 0 . 5=very, Ve _7-7 

# Little Very ligh t LL I 

# ~ ~ 2= Light BS~RT?AL 

## SORENESS ~ 

# • 14-14M 

# S • 3= Mo derate RE THROAT r H~~?,RSF'~T~'C 

### g ~ to 5 =



# > , ha

# t oxM

# SS Heavy 16 Heavy S

## AL 

## DT S 

## U1-L4

.R' 

## E/ + I 1 NG~ 'r5 TION 7 to 9 I~V ~ I i ~ ~~ 1 r 

## Heavy EvZING Ve. ~



# ~~~~ltll) ~~~ I 10= 

# _ Ve

## r-y, Ver

y EST TIGHMESS / SM IG 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 

## ~T-F 

# (0- 1

# 0 )
~ I 

### symptoms 

## & discomrort I 11, I 

## 3 ted several hours, / i1d they cause you to
I J _ _,~ 

### Decrease optional or recreational activity Lis t Take additional medication Be triable to pre form the s~ ~-. n= = .Lm t of work tha ; t you could normally perform 'ILzrn th is workll oad level ecc„n 1 aisre~ard fati g ue ) 

### Be tmable to perform your usual. work activity or level of productivi ty (* oc ci-mation, schoolwor k , c^ tical household duties ) Stay at home sick ( lose sic'_{ time from Tr -O r?-c) Visic your Dhysic i =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 ' Scal e MEM H L~ w w w H r-a H N H ' =d ^ r ' . ^ 

### Mr E 20=

N-DDERATE U 0 ,-Nothin g n c E-4 i~ cHr~ E--4 

### a t at a 1 Il~?~ 30=Sr-=, v c n 

### v a a o w o c~ a w a ~ , ~, a 40==AP . ( 0 . 5=Very, very Little I 1 ; ~ LS I 1= Very IiQn t 

# ~ ~ - -S ] 

# I LL 1 

# 2= i. ig~n

# t 3S=- 

### ! Ai, SOR zNtrSS 3= 't'4der_t 4 ~ to 5 = ~ ( ! I, ~ c T_. I j Or BRE~ `rT i , I~ I ! I , 'AL i,T 

### 7 t o
7 7 7 VCr-~/ ~G~ .~•I' J 

### 110= 

# - Ve~-

### 7 , ve_-- ~L~c„~ I+ ~ i, i ~E?v~~ 

### =' CTTO N '-=
~,~- _\ 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 fatiTs e) Be t~a-~ to perform youi- usual work "'activity or e r 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 SY L = SCORE Sr-it-ET M

## UP 

# vs.rE

# cr NO . 

## A= Exertion DI~ID . ,~ cv C., Scal e ° w w w ►-+ > ~ ft 

### CORING 1~-i r - 4 1-+ r1 F-~a c*l N 1 "'" 6q VOtL'11 Y .- ~T 

### E 2

### 0 -DE~~ 

# Ca U . E-~ 

# U . E-

### 1 E+ H C ~ • 

### ~n U) M o f G= ( n cn at all = TRACE 30=SE o o a 

### i rx rz r :.~ cz ~ .• a' 0 . S=Ve_ , Very - 0=`^=rLD 40=~1CAP . Little PUUM z= Lio-ht :Tt3SSO~~ .S S qA s- .-Ell r S l , t ~~~ 3= I~deYat e ~i ~=(~c T I y L to ` 5 = 

### r 

# ~A-P

# .C.:S> SC~! --.Ni : 

### a L 

# 1 f ` H~=-~ y

~ P MT-1 

### =s OF B

### RE a?S i i ` , 1 / C75 1 LT 

### C~ ! G= 2a-TJ cA± D IEGL

L 

### ) OUES =I ON 7 to °- -- I l 

### C,- t ! ~c_-- 

# 1 ~~~ 1 1~, ` ~ i= 1 I VE= r- 

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

# ~r,

_ i ' / ~ J= 

### Ve 

### rv, 

### V~- ~-+ 

### Heavy ST 1'_t=: ~~ .. .JS

### / ~ f t 

# ~~~,~:~~ -~~., ► ~ ! 1 I►_ 1 ! , f , , ~ ; ~. - iC

# ti 

# AI~" (00 ) sy = tcros F~ disc = ort ~ ) f 

### s ted several hours , uld t :he,7 cause you 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 

# 33 SUBJECT NO
. B )ATE Exertion :OrID . ° r-i 

### N r ) 

### Scale ;COR ING w w w w H ~ °1Wt IE 20= %-DDERATE cr~ cH n 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 gh

# t UBSZEK?AL SORENESS R AIlA1~ESS 1 ` ~ ~ { 3= I-bderate ORE ?HROAT 4 to ' 5 D r HOARSENESS) S Somewhat Heavy 

### :ORT NE SS OF BREAM 6= -Heavy 

# ^
-S

# aL D±s~~La .~ / 7NG"r .STION 7 to 9 = Very Heavy 10= Very, Ver

y



### - :EST TI~SS/ Heavy =RICTIO N

=

# ~ ~ =` '•-Da~-~' + ~ i ~ L : NO YF-S 

# I II I ,_11 {
~ S 

# ~ =1 NS { 1 i TS-7) 

### )RG EXER

# Tlov 'ALE 

# (0-10 ) symptoms & discomfor t .sted several hour s :ild they cause you to +~+ Decrease optiona! or recreational activity Lis t Take additional medicatio n 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 .VR1 1`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=Verylith t I ~ ~ ~ I ;_~ ; t 1 I 12= Lignt BSTEPH AL SOR . F~Ii ESS ASdA~i ESS 3= Nitderate • l ~ t E z- ~~~(S) i i L to ;5 - ~ ~ I ( ~ t~ ~ I l SC~vZa t 

### Heavy :)R=S OF BREATH I I 9 1 

# ~~~~~0) I6=v~vy EAT DISC-T-=-E/ 

### ' t t ~=rSi70N ' 57to9= 4e_y re ,- 

# ~'~ 1~ JI ~ i,• I I I I~ I~~>>! i I~ Y 10= very , r 

# T~

~~ 

# _ ST TI-1! IESS/_ Heavy -TFLTG1ION 

# I C

# -ti T E 

# l xu 1 

# 0

_ .~rr i : M _ LLC _=__! UV ! I I 

# _ s~~vs ~1) I t I ~ `
. iE 

### (0- 1 

### 0) 

# ~2, symptoms & discomfor t 

### :red several hours , d they cause you to (00 ~' t"t t 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 ON ID . u : N r~ Scale MRIl NG ° 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 .I j .AL SORENESS AIdAMNESS 3= Nbderate

►RE THROAT 1 I
,r HOARSENESS) 4 to 5 = So =NIh a t 

# nx TNE

# sS OF BRFaTH 

# xeaVy 1 

# 6=Le?w SAI. DISCHARGE/ 

### NGFSTION 7 

# to9 = Very Heavy EEZI ~itG { 1 I t I , ( I~,'' l ~ I I~ 110= Verv Ver- ; EST TIGIT

I'NESS/ Heavy 

### , STRICTION " II

# G r E .~DAQIE DNTAL : M YES 

# { II I r ~~ ;I I ,

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



### - 

### ST) ! I I j ! 

### ZG E=TION 1 

### J-E (0-10 ) symDtoms & discomfort 3 ted several ho ur s, 1d they cause you to -F , Decrease optional or recreational activity List Take additional medicatio n 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) Visit your physician d~ i - ;sit an E:-r.er~ency re=1 ~

### p . 53

WIJr v'-'~1` I 1 

### IBJEG`T NO . J099 ss, Borg Exe rtion fiID . ,~ Scale X7RINC ~ ~ ; tw n ►-+ r-t f-+ cv s- A c n 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 lian t z= Li g .t 

# BS MPI.IAL 

# sox

= 

# S a1vA~IESS ~ ( ~ { l ~ 3= 'Mcderaze RE Tf IRQA S C_ to :5 - 

# = In

# ~

sa"Tatz 

# j> NP-MIT
O R= 

### S OF BR F 

### 4Tti 

# 1; 

# 01 C-S 16= 

# Ueavy S 

### a?DISM



### ARGc:/ / to 9 = 

# -r T ~e ;r r_ ~ 7 LN 

### G 

## L±o=very,very :ST TIC11 ~S/ Ee-a

### vy = 

### CI`TON 

# ~( I ;, ;

W 

# c t 

# ~~c ~~! 

# ' d ; 1

~NLA-L 

# :~ Y

-FIZ ER~I T

# ,_~ OIN :ET

# ) 

# : :F 

# (0-~0) sy = toms & discomfor t :red 

### several h

### o ur 

### s, O I, I drthey cause you to 

# C I ~ t--~ Decrease optional or recreational activity Lis t Take additional medicatio n Be unable to preform the ma . -dm+ 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, critical tic -,! household dut -J'as ) at home sick (lose sick ti me 

### from w o

### r k

### ) 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 OR M IG t!] cwls ~ 

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

### c~, ►-+ c-~ ~~~ 0--Nothing EA 14 El P E' at all N 

### =TRACE 30=SEVERE w w w _Very,Very ?~IS) 40=INCAP . 0 .5- Little ) UC H 1= Very ligh t 2= Light JBS7 ER Ij .AL SORENESS AIdAIUM SS 3= Moderate 1 R E THROAT 1 t I 4 to 5 = T HOARSENESS) Sonslat Heavy :ORINE SS OF BREA TH I I ~ 

# FJ ~



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

### AI, DISCHARGE/ 

### NGESTION " + 7 

### to 9 = Very He :-

W :vy r',,' ✓ , 11VV I 

### , 110= Very, Ve r



### _ ; EST TIQ3'INESS/ Heavy 

### STRICTION 

# T IGUE AD-ACHE DN

# r A

# L : NO YE 

# s E IRRITATION HER 

# SYMPT 

# n N

# S ST ) ZG EXERTIO N 

### VLE (0-10) i synmptoms & discomfor t ;ted several hours, 1d they - cause you t o

. --, Decrease optional or recreational activity Lis t Take additional medicatio n 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 ~+] a r~ 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 e n 

# _ ~ ~ . . 7- .cV ¢ N N m w a 1114 1G (> . -1 H N PL ~ ~ ~aN H .-1 w a w t~' w w O N : ..a cO W > A . 7C H¢~ W W .-~ . . a W ¢ O H P+ H H W O O N 0 pq w p, 2 04 co & A H ~ W A O N .Z > N > U CQ O co U

. . . .~ H t=] U W W W P .' 0 ?G A W C7 WO[~ 60 [OC~ t G,.~ 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, I t t - 1, 1,7 i <>>t t sY > ; u~l ~S f , 4 ! 7L 3t i'i ic f ~3 4 t wt V> l u VS <<J1 4 ' t N OG w N U) Z pq P4 w x >t ~ ~ o ~ tn W 0 H H ~ ¢ W x ¢ O H O¢ w' H w En 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 O N ENTRY 114 Clu\14BER IN CHAMBER ON EXITII4G ON EXITING 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 P OST

# p.~~

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## s c o = _ ~c ~p . 02~~ z ` ~ : ~ k G < < G - _ ~ u: e 

### La= Al- 

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### c ;_2 

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### 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 

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### v a ` O .=sr°~a_ : 

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### p . 57 9 01 MIS

S 

# ~~~~~~_ :yQ_J~~~ • ~~~1 ~ ~ D 

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