P)p . 1

GROU? c-, ~

SUBJECT NO .~

DATE

COND . C ~- r z z z

SCORING

!=NONE 20='40DvRA

R,ti

x _x a

a.

~ ~ v

)

~ ~

C V -`= C

m <

' ~-+ ~*

C F C

)

5=~°ACi 30=SEVER-7 E- x

U

C

X

Cr M m C E, 10 =_~?DD c, 4 O=IVC? 0

. x u x a x o c

COUG H

SPUTUM

S S S

JL SUBSTERNAL SORENES

OR AWARENES

S SORE THROAT l~ ) 7 ?

;~_ :~~_D~~ ::~~5 ~ ~ 1 ~ ~ • I ~ ~ i ,

SHORTNESS OF BREAT H

vAS :_= D -TSCH:_G E

CoNGESm_o N

'vEELZING

CHEST TIGHTAFESS'/

RESTRIC T ION ~ L

FATIGU

E HEADACHE

l ~ 11

r RO N T?_L : NO Y ES i

E':E I RRI"'sT 7 0N

E- i-) )

OTHER SYyDTOMS

(LIST)

= sYmo toms & disccrn_o ; .t

=s

3

z ed several hours ,

• ~- .~ - u?d they cause you to :

e er to A -n )

A . Decrease oozicnal or recreational activitr L i S• Z

~• Take additional medicatio n

~ . Be unable to oer'o :m the ma ximum amount of v o :'{ that you could normally

De- io*_' :1

J m'~-•- t^_s or_.'_ozc I ?•re cc :n11_s-°- s_ z _•ie)

3e unab_- to e - r - ;rcu usua .:o__ ac ,~ ,_ o '_ e- o

~ F oc_ Cr __ hcus c ~) : -- _ a z S ^c _ s _

- '! -- -- - - - _

` >• , -_, . , , _, .
~

C G AT D

/ - - • ,--~ c c= •-

~ - ~

c -

_ - <

~

SOG' _ jC ~= z a2 c: c. x < -

T =NO N *. 2'J=•ACD~R"_r= ^ C= - ~ c c c c c

~=-P -1 0 .~ 3 0= s c r

f

-

C ~ t_ -

1~J='r7 7 .D 10= 7 :fc =' }`

c 0 UG HT

s2U"`IIM

su3s LE"[ `L s0 R7-:r-.:-S S

0a 4:ia3_ .dSJ

/0

r- fi0F_°S Z aLSS )

7=ORN .E-.SS 0? n?.~ ;

-- J 2

~ 7'Z'r=0 y 2f) lo

Z- rT c- 2oI

_v-r_G^'L_r_.JJ/ // ~ / •/ ~ ~ I ~)

C n .~

IIZ)

:___~~ ~ ~ • / ~ ~

vo~

1 Y 7 m_ !0 l: w~1 / I ~ l' I l I /

~ ..~T) 1

_ ~~ioas & discc

S2,rPro _ QO('_Z'

:•s_pr . r ~l

S

they c a use you to .

t o

Dec :~_se ooiionz l or r e c- E _tioaz j zctivi~-_r Lis t

Tat~ additional m e dica~io n

Be uIIZO i ° to De :OL m `72 Ma ii ^US amount Of c.O*':: `1? roll coul d C_O'_ 11 j perfor m

p e : F o I' :

Turn i :'_ s GOt' ~~I O ad 12 'r2i a0=1 ( 0.:sT'e g 3 :0, r3 t i 7, u e )

Be °`o Dz" 0 ra tOU=' usua l

~~ GOL t~ zC t i'ri t 'I or

L°'/°1 p : D~pGruC un20_

_ ~ ' OCC i0i1 , Sc^o0~'•:O'-_ ~ c'_ . LC3_ 1Glls~ .^_O ~ ` C~=_ _~ )

•I___~ _ -~_ . _r~---- . .

I-- -~ -- --_- _ _ ,'.
C' -

:7ii -

= :ra L'rE 2 0 ===e D a^_^Z cr C-1 C;

~L a2

F ^ C L C.;

=-~_~A-C•y J

0

_

tI

~D L

r~

U= 7 _YC~__

,r

X

_ G7 ~_ ^

UG,

c,~_~

3S 1Ea ZY A:. ,

'

IR -v N =vJ 0 1 ~o

E 0 14- .1S E Y 5 , 1 I~ ~ I i l/~

mIT 7-SS O^ 2 C)

~ ///o a 2v ko I

l'o LO /Z

3 .~~ D 7-- sc HE- c~/

1 o /_Ho 1/0 116

T _G= N -JJ I !J/ /

(/

)

V

// ~

!~ 1// 6 l

V

: I /;

. ~ 1 GJ L ~ 110 /

~ .1C 7_

~ D l 70 W

TT _, : N 0 f-I E

______o ;~1 _-o :r //0 /Q(0 o ) r~ l \ ~V

6

=~ s•rt.~ ;~~ ;.f~ I

T'S ?' )

C~JC~S

several

& Q1~ Cf1_

hours ,

. ~

j

::he_r c a use you -- o

to "A-E )

-crease oatioa`' or recreational zc~irit•_: List

z -Sa additiona l ,e d ic a tio n

_ unzol_ to pe-_Jrm the m z : z ura amount o~ Jr :•; ta~ rou could

_r tor a

urn this 1~ ,re1 do : :a(disre g a_a :a ti4 ue)

1 ocuc ' r'-t ;r

_ un ao__ to oz-_or our usual vo : ac - _r _; or er~_ Of o r

c_--_c_'_ c u°_ 2 . !~ u i_s)

: 'r at O Cs Z2 5-C
- Ii _y j '

\ ; 4~ - ~~.._.y.-

-DL__ ~

- ~IV ~i, U y-Y~

'DIdD

C0H!

.

~

n

o r

TC ~ Kp 6L~7 z m G. r G.

SC C ^ -

E 2 0 =_i'tC17" IDI ! _N09 r. .L O. E5 ~

C C

,

-P zCu }0=S EVE .°.~ ~z c C ~ C1] a:: (n 5~-: Cn G C ^

~ =ffi1 7 40=7_ycl'_P_ X X X G ~ ~ ^- C

. ^ C -

OUGn

16- 6

P:T?'Uu

J2 S T .`.. RNA!i SORENES S

AWARENESS ///o/O

?I E M

. -

T

HOP_°ScYESS )

l

. O n_"T h. S J 07 D 7 v ,- r.-t L-

(~ ~ ~

V f l~ ~ 0 ) t D /O/o O ~

_sr T . DT s C: AR c E /

qC-LST , 0 N 20 l0

7 c

=ST T= C_ =~"i 7

SS / ST~ _ C !~?~

f. ~ ~,^ )

_^i.Ons ' 4.1 s cQra_ o ~.L

several hours, ✓ `' / ~

they cause you to :

to ~-H )

Decrease o p tion2 ! or recreational activity Li st

Ta k e additional medicatio n

Be unable to perform the Ma X? m u[Il a mount Of v O'_- ,i t.7a t YOU Cou l d norWa 1 / f

per-for m

Tura t h is workload level douz(disregard fatigue) .yj

Be unable to perform vour usual Gror`t1 activity or 1 e~re? oL oroduc

r

occunation, sc':oo1-.:or't, critical house^o 1c dut ; °s )

Star at >o s_c'(Lcse s_ . . :,

your J r ~_ 3 2
s`~i ?i i

G~uP , • ,

'1 SCORE SHEET -/np 5

SUBJECT NO .

'0

~

DATE / Fz~e

COND L~

. C I A Cn H c e

SCORING vi Cn M ~~ ~

1=NONE 20 ~DERATE

P4

~ ~, ~' F ~ z~1 ~ ~ H O=Nothing

at all

5=TRACE 30=S7VFRE c o

w P- w

10=m-= 40=~TCAP . 0.5=Very,Very

Little

COUCH

Very light

SPLI'I'UM l I p `

l I \ ;~ ; ~ 2= Light

SUBSTEB.ITAL SORENESS

OR AI~IA~ESS 3= Moderate

SOR.i =AT 4t0'S

(or HOARSLVSS ) 1

1 ,

Sorr,--,„-hat

\

SHORTNESS OF BREATH Heavy

6= 'seavy

CO` G F _.: , T I O N 7 to 9 =

Very Heavy ,-..-.

Jhr :-ZPti G

!~ I ~ I \ I ~ f 1 ~ ~ ~ 10= Very, Ver-~

=

RESTRICTION

ST TIC-t'INTE SS/ Heavy

lit I

r`' TI; GjE

FF--'-DA= i o, ,~i

AQ

~.RI=? ON

C) I 1 1 ~' ,, I ~ ~

0'r`"--FR S~ =N S

(LTST)

BORG EXERTIO N

SCALE ( 0- 1o)

If symptoms & discomfort ;

lasted several hours,

would they cause you to

-n r _ ~ , / ~ ~ ~►

A. Decrease optional or recreational activity Lis t

B . Take additional medication

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

D . Turn this workload level w-n isregard fatigue )

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

(* occ=ation, schoolwork, critical household duties ~

F . Stay at home sick (lose sick ti me from work)

G . Visit your physician

H . Visit an emergency room
GROUP

SY2~PiLI ? SCOPE S'r=T p

1

6

lbSUBJECT

DATE Borg

NO .

o

:

Exertion

COND .

~+ c.

I M Scale

SCORING

1=~Wr]E 20 ~DDERATE P-4 `

1

' ~ M

C F+ H E0--'Nothing

^

, ~)' N U) 4 z i E-+ H cn o w v cn at all 5=TRACE 30=SEVII'~~ F,:: F-i , r~ w

1:41 0

10=== 40=I2qCAp . 0.5=Very,Very

Little

COUG

H Lijiilverylight ~ SPUTT

2= Light

SUBSIER1'LAL SORENESS

OR Ab]AHZ,qESS l ~ 1 1 ~! ~ I 3= Moderate

SORE 'glMAT

(or HOARSENESS) 4 tSoui--w~ t

Heavy~

SHORTNESS OF bREAT i

, ~ ~ 6= H2,:V~~7

T~..SAL DTSCi,E--/

I CONG'~,S 1?ON 7 to

9

Very Heavy jv~EZI~;G \ t

1 G Very, Ver.

=ST TIC;H`_=SS /

RESTRICTION Heavy

1 l '

FATIGUE

~ADACH

E FRONTAL :\TO '/_S V 1~ I` ~~ r i

EYE IRRITATION

OTHER nNS

(LIST

) BORG E=TION

SCALE (0-10)

If symptoms & discomfort

lasted several hours,

would they cause you to ~-

A . Decrease optional or recreational activity List

B . Take additional medication

C . Be unable to preform the ira~rnmm amount of work that you could normally perform

D . Turn this workload level ,m isregard fatigue)

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

(* occupation, schoolwork, critical household duties )

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

C . Visit-- your physician

H . Visit an amer~ency rcc:~

/'0Z~~~~
p. 7

Cs ,l v eyt .~~'+e-`~:

CP =CIH., S C-- E =_

jb ~ ~

~ZCL~ ~~ t ! t ( t t ~ f

t

SL3.m:. L~ 111 z

1{t BOro

D2= Exerrjon

Sc co -

1 e ._____

vl.~J il.:

C4 = Cr, C!] Cl] ~C t 1 ~ 6 ~ ~

P -; 0=`To 1=`~'~tr ZO=_~DEF_' ~ cr` c : c~ c1 t t E ~

~• C; E, C E; C r-• Z t E- H ~

i-r at all F-'' Cn Cll Cr

~rr , 0

P. a a v~

.5='7e.ny,Ve_-I 10- ~.J 2, TCAa_

. , t Li tr1 e

COLQ_1.

1 110 ` 1= Very li?rlt

SUH =js^-T c1F^ - ~_-S S l I ~t t

OF,

SC== _= 0-== ( ~ ; ;

; L to

S) ► I ! ! ~=~-~:

G7 -:Z ;?= ~^- I ✓

I/ 4 i ~ ~ ~~ ~ I. ~ i i

c= ~~_ .w T~

Z

! I 4e=- = ° 7

°

iaa-r7 ~.v.-~~~ j ~ ► ~ I~~ I ►~ f IC) 16 1 ~o l, a_ ~ , = v r- ~er,

T~~

~C

Z

y

l{1~~ I ~1~ II ~

NN*::,-_:_ : ,E `~~ f ~ ~ ~ ► ! ~ ! ~ i C ~ ~ ! ~ ~ I

-=-==-y ;lililil ~IC ili) i ; ;l i

t t L i

~ / /`

Z ~=- (0-1-0) a~_, t~t

if s;r,l,ncrrs & di.sc..,forL C

lasted saver-al ho=s,

w~u1d they cams e ycu t o

A . Dec=-,e opti.onal or recreational activity List

B . Take addition _! T-r_edicatien

C . Be LmaDI.e to preTorm the ur-_-dm= =Unt of w-or'_ tCa"~Au cou._ .d normally pe.r:Eorm

D . Turn this w-or'_~cl .cad level -Fow-n(-''aisre;s.rd fatigse)

E . Be unaiD ie to perform your usual wark activity or level of productivity

oc`.mation, schcolwork, critical household auties)

F . Stay at hcme sick (lose sick t*-ro f~=

G . Visit your pnvs:c=

H . VL~i _ an =e_r-en._ r rscm
GROUP 112- 1~7 L

SUBJECT T

DA~ Bora

"o . O5-Z

3 Exertion

COND

SCORL~,G

.T a r~ Scale

F-~ ~J

1=~r~ 20=-\,DDERa=

P 4

cr'"~

: F-4 ~-' Cr) 0

T =`o thing

E-4

i H vi M at all 5='IR~4Ci 30=SF 1~'~F o o e

a aCn

10 `^T_..LD 40= EN CAP . 0 . 5=Very, very

Little

T

91-1 LLJ]LiT1\1l=Veryli2±it I I~ '~

S PUTRz

2= Li~.t S'uBS=F~IiAT SOR=S

OR AIjJ.A'~~SS I I 1 I ` r ( ~ `~~~ 3= Moderate

SuRE IZI---RDAT 4

(or HCA ~.,i~^ Sc~'~a

;S) 1 1 I ~ I ~ ; to

:~~t

Heavy

jP_CR_T~SJ OF RR~~ ~i I I

Vi

_

10= n2;~'l LN~~~ D1-QC+_~'~.r'" i

_

~OV r 7 to 9-

~ l ( ✓. ~ '~er~ he=~r:

J! ~L

O 'I OV ? " 1 0 Very, Very

=ST 1_~:1 1VLQS/ i i ~ 1 J

RES_LRI-1 =N f \0 I ~

~

l~0

' U ~C, ~ , ~e v

Y

~ ; ► ~~ ~ ~

I I' I ~ I~ I I'!

~

7~=fT)i_C`~

~cCN~^?~ '--1U J Y Z

(-L=S =)

30RG E` JG .==-, ON

=r (0-10) UO

Lf symptcros & discomfor

several hours t Lasted ,

,-ould they cause you t o

k. Decrease optional or recreational activity List

3 . Take additional medicatio n

1 . Be unable to preform the mac~~m amimt of work that you could normally perform

~ . Turn this workload level down 3isregard fatigue)

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

occupation, schoolwork, critical house-hold duties )

Stay at home sick (lose sick time from w-ork)

Visit your physician

i. Visit an e?^ercency rocm
p.9

7~

G:ZOLZ'

lft t Bar, t

=1AIE

^ Q C7tSt C7 Z

C''.ic

2

C

~CORLTG

:,IND . e

C-•

~

V

<

r+ H N h-+ c'') L= 1 C: Ci Q=

'TO LttL* r--:

cri

. C. f E- ~ E- E= Z 1 t F- E= r--. =

U] C( t C_ U? Cf; at al!

5=L7--A-CE 3a=S 7= -,5

1 c=~rrT~ L' ~1p , t -J-7ery VerT

Litz-' a

COLE Very IiQRc

cr~.~~Ilt t t t ~

7,-

K

_ _ ► I~I~ ► ~ ► ~ f~ , ~~ t,,ll l I~I 2=Li

C~rl

. t- T.i~`!. fl ` \ `f I1I I _

.. :

. rTva_ r • „•._JS t t~ {_ ~~Ce_~

1 I,

._. .

t t ~ ;~-- - _ - c-17 y I { t t ~ ~ ~ ~: _

,,,_

^\ ~ ~ 1 ! I ~ I -

t ' i ~

t ~^;^."=

SS 0-7 BK=`= + ~ f f + i f t ,

i • 1 , ' t ~ i Vc' ~ __= 1 --- ...J ~

v/t ~ • + f r'~

_^.

_ C_r"-q

~ i ~ + ~ + t ' i

ti-__~.

t ; t

~ `~ • ~ ` 1+ ~ I{f 1 I ~ ( I ~ I

- : r -~-- - ti I t ~ 11~ I ~0_ ~ „t l

- Sy

-yS ted $e`Jera

=tams & ai sc

ll hours,

„-- ;n=orc

~ 1

~ ttt ~

~; ul d they cause you to

Decrease optiona! or recreational activity Lis t

Take additional medic--t-;on

Be unable to "preform the ma-cim= =Cim.t of w-or'-. thac you could normally perform

D . Turn this workload level ca -n sregaz'd fati91-:e)

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

oc=.mation, sc_hcolwar'k , c~lt~cal household duties)

Stav at hcme sick (lose sick time r" ;-cm U,-or'_c)

Visit your phvsici. n

V~~ ~- an emergency rc=
- S~~_~!crI ;.~.. Sr ,- T ~

5~.: -

'7

~- ► ~~1~

SUBJ ECT

DQ-'r^' `~( C~ r-~ ~ L' C

.

E5 ~°= ~-CI1 Cv`

lYL

T . C~ C^ Z

21 ~

r4 N SC

-7,.

c=? e

cr ! E- t 1 t r= h- ' cl

.SCvR~iG F Cs LK L-' L' G-' F t 1 1- d

~ ~^' Z U] C(1 C! ~G 1 ~ -7

c n G=a t t` CJ 0=~70Cz1Ln

C^ 2` E-+ o

-~~0 -71 =.

~' cr C. ._ I2 U7 C 1 l l C=: CI7 Ul ~ GL all

S ~X; X L= X C= L- t t t; C C^-f

~ T p t^i ( 0.5=~•Te=y,VeY- 10 ~ 0=~C~ . 4 t t Lit-z e

C^vL Cz ` ~~~ ' f~ ! ( 1 j!~! 1 ~/ t~ 1= ver-y I, Q~ t

SPETJ'T_L'1 _~` li~I`I~III~III~I+ ;_ IL;~l t{ ► I 2=L_ =--t

S-,:Z- C __SJp ~~~~` t t t /

3 _ c----

` r : i I ( t} y✓1

_

t3 ~

G=

% -c °-

. ---i

!C= V~;, v~

.~-~

t t _

.~~_ ~~~f ; ~! l~! !~•;<i ~l~} ttt

N

_

l

~___.~__~~{ ~ :~~~i~i~~~i~il~~~i~l ► l' C..~-

l/

L sy=c~uzs

A. Decrease ootior-al or

Th-EHL

recreational activity List

, H

B . Take additional medication

C . Be unable to preform the m3--dun-m =tmt of work that you could normally perform

D . T=n. this workload level dow-n aisre~ard fatigue)

E. Be unable to pe_-=orm your usual work activi.ty or level of productivit<y

(w oc_.mat'_on, schoolwork, critical_ household duties)

F . Stay at hcme (lose sick Hme f--cm G,or'--c)

ycr- pnys;c=.=n

h. Visit an room
1

'L

i

T'

S1~L .i r.~ MID , ! !

.

{ !Ii

I!I

ic?" -

DA- C ~ ! f 1 C=' C ~''=

{ L

_CP.

; C2 G z

Cr`

T

W . ~ / L t G

r-. N C'"? I-- G'-

LJ t~ TG C=2 = .. G: =.• .C- Cl] C!; Cf7

<

~ ~ cr t! t c; 0 c7-~-~~2 20=~EDE Q

''_ C: C: CP L' C!: C! C t 1 r-' C!'. G"1 ;- c= a

~=~ACZ- JC C-- C, C=-~

1Q-~ LJ=~iC~ ^I 4 1 a.

T_

..OI iR Z -Z

, , ~~ ` I ~ I ~ ' I V

.r-T

-

_ ~ .~----~-----~-~--?_ Lic~

.r' = T~~~'c~„~

.

• { 1 ~~

~ t ~ ~

;C:' .~-'~.~

.•~~y~ c =-_=

=,-

_:~=~~r...~ . . G= ~__`'~: ~ ~ i ~ { 1 • ~ < < < ~ , ~ ,

__E7 '.:r

`

; =`-'-

~~~~ I ~ 1 I i\ 1 f 1 ~ ► ~~ I~ l ~= Va-7 VE-.-

-----~~_,

_ - ~~~ VJ ► ~ I l • I 'I ~ ~ '.~~ ~

A

~ ~ ~.~,

_-_----

1

~

----. {

f ',

~-- !tr ~

o

'- (0= ~) ~f ( ~ ~ ► ~, { l~ , ~ ~

:: Cl.

-

.S. eveY.=-, hours,

! I ` :)u1 d they causeyou to t

, ~ . . -

-

Dewaase optiona? or rec=e.tioral activity List

Take addir.~cr.al medication

Be unable to prZora-i the mc_~_m *n amnunt of work- t_L-.rt ycu could nr~~~lly pe~or->

'I'=--i this workload level acw-z a sre~ard fat? m~e)

. Be unable to per-,;-zorn your usual T-mr{ activity or le,,,-el of pro~ctitizCy

('` ocz=a.t=orz, sc^col~~~r?~, critical household duties)

SL t~~ f~-cm Gor'_c ) :---,7 at hca--- sick. (lose sick

V; S

-

it- ycur Frys

V=S ~'.: an roan
h

~t~ •~ ,

c~ ~I ti~~

3r=EOZ

DP.~'~ Fzcerzion

ZCI~U7 . z 1 1 1~ r=_ ~

~ p HI

Sc=1e

„

:OOR y~IG ~ 1- a,

cn cn >e t ¢ ^-

`v

r,i c

n r- CIE_ c-i H z H 1

: C._. V1 CIl C t 4~= U) C1~ at a

-- ' :-?~•-CE 30=S7T~'~:,

La-•=, LC= E C.AP .

0 . 5-,7e- 1 .Ve_

MUM i=

Lit•?e

Ve_.,--y 1.; Qnt

2= LiS~it

;u-BSq=I, Qj SOR:_~;5 ( r 1 1t ,

ATJAk ;j - i L`C_=ct?.

~ ~ OBy ~aL. 7 '~ ` r 11, 4 to 5 1 1 -

C?"

c

;M= vTL~

..~,7

HOR ~-"~S OF ~~ a"'~ ..~ _

; ~ ~_ ► ~ I I ~ ! t ~ ~ I 1 ~ ~ ~ a= _ ~~1-~

,ca;, D~~~.,_aRG'_'~ i t ! ~ (~ ~ ~ • ~ ° •

~`cJ~='LIT I i~ ~ ~,11 y l• 7 tO

! i ~ I! I ` ~ i VE=7_ _ ~~77

~~'"` !I I~i I• 11 I~It~l~l I I I

T G S ,

, Ve_~- ;7, Ve_~--;

! , T--- -

~ ..~ Fe="7v

~ ~cti~ ► ,I , ~ f ~ l ! ~ / f ~ ~ f

3

1 f ! ` V ~

111 1

=1)

~LF. (o-? a)

= sysDt= & 'cii scoczzort

:sted seve.-_ a1 hot=s

mld they cause you to 1,1

-~~~ +- . * ;1s1 _

. - ~

Decrease optional or recreational activity List

Take additional me3ication

Be unable to preform the ma--dm+ m -mLmt of wo

rk that: you could normally per_Eorm

Turn this workload level cow~ aisreUard fati Tse)

Be unab-e to pe_~orm your usual w-or'~c activity or level of productivity

occ-mation, sc:neolwor'_c, criti:ca1 household duties)

Stay at h=.e sick (lose sick time from wc

rk)

Visit: your Physician

Visit an e*- r~ency room
p. 1 3

~-14 ~ ~

ccw c c `r' c=

• - ~'[ . ~ L C

e C

C

.

a Y c' ~ ^+ _ ^+ c. r_ - r-cs rn > c~ ra a: r_ ea =- ~

a o n. -:~ > = C C ? ~ - C = - C ~=

+ r3 3 :+t - _ - ~ _. C^ ? ] ~ _ _ _ .-. C~ C•S - C: a

a = n _ ~

ZZ)

., R - r- 1 r = > ^ti ~- S s y,~

a 3_ = c I - ~

N

. _ Y

•'( _ ~ ".~ ~

. ~ Y _ _.

= ( . • 7

- - ~ 1 !

• _

~~+I f 1 f R! ! I 1 I~ I~=V== =,= -, -`----

~=

! ~ ~t ---- r- ~-- r- { r--" C -- . ► C -~-- ► ~--~ -{~ { =~ ~:= u ~

70

{ r I f- f- r rI.-

Or

3. T_~ -,4dj =:. . ...L

C: . 3e tz=ccLa [ pC _c- `rn--- - =rac :- ai .t=cr:c cW,c ]cu cz:czi: aa-- "7 pc^~r+.

D . Tu.. ~'- va _' ::d Ieve? davc ( a~_3~~ .~~~ue) .

lrrei o ; p_oduc~ =~i Be ~--ola :rou= sul ac='_ or

(,* o~~~z~aa, sc .oo2-vr , c:~~- =-.T ha~cscaol i durj -s) _

~_ ~ _~__ 11 __ __ ~ ". , lC'~'-',_ •
~ o .

\

' jlc' 1_ ot p

14

D A.

C ( ~..lY - L C

c'- . r-~ c c. `" z z

C' ~ID .

~ i..7 ~i_TC L' C z C0 G: F G: ~ iG <

,r-..,

'

l=-,TONE 2 0=',r n D EZ E c~ c c c ~ C

~_-_ C 3C -~ e - v - :[Y; ~ L- C r-' cc L' Cll r-' Ca C G G1 G~ `

(J=!tTi.TO 40 = 7_ i Cc_D . X F X X X - C. ~ C

?UTU M

J2 Si':.°. N 3L S 0 RE LT :S S a:y, R c NZS S

J?E 1_a oAri

o? fi0P- 31Sc,NF,SS

=0 R"'w;E SJ 0, 3~~~T =

1 r W,li ~ v

--ss= D Is C :.sF c E /

~csT T orr

~~~ ~ ~ ~

P\,

►

_S T~~~c~

~, « G~

~ '__L NO 10

T =7 T .

I— -__n i Q . - - N I j

3 ^O

S: L

.D oms tY di sc^. .t .or

se-reral h ours

t H ey cause you to .

to A -cT) ' I (

Dec- ease oocioaal or recreational activit y Lis t

Ta k e additional medicatio n

Be unable to oeriorm the ma :_ .yum amount of work that you coul d normally

oe_ *or m

Turn this workload levei do v n(disregard fatigue )

B e unable to Cerior :a `rour usual wo r :ti zc t 1'ri ty or level of DroQUCi. i`r= Z"y

( 1 ocC'1D a~ ion , SC .:00~ O' C° _ .

. iCal :^ous e .^.o L G Q.S z = es )

" ~ a Y a . . ., . . _ c' L o s z s _ C _ .

. . i - c z-, - ., .
p. 15

•- , -

~ • _~u

:

.rr~

`-

•

0 a _ N C ~ f G7 G. }1 C: - >c < -

O NE 20='.=0 D E AZ cr;

-.a p• f^ G~ n

-- Q 5 C .-. ~. r_L' : T1 `-: G- C r' c17 =' Crl U] C G

LD L O =7 :V IiL:2 •

x ~ X x ~ ~. ~ V Al r^ C 4 ~ i, ~ i= ^ ^ =~'` C ^_

JC

UX

13 S1 Z"JN!?1 SO= ENE S 3 a:Y A-2 rwz~ S S

E T ER 0A

-

T,

ffOr°ScY: .S S

DE sc :s~c~~ 1 ,'

l 4 1 ~ t !

I

c L. S m T Q LIZ

- ~. `:' `~ _ ~- `

c T _ 0

. ~ i

_y

. S J ( ✓

~ I

T O

=.7.7

m =.

n rci 70 ~ --- .~

~ ~ S •r ..i : ~~ ;.t~ ~

i.J475 & Q .'SC .^.. :a =or.~

s e-rer~l hour s

:;'-I e,/- ca- use ,rou o

ooticnal or recreational List

2CQti.CC12 } QI e- J C2v10t1

_ L1 :120 _1_ to De- :- ' O .r m the m S :' 2 u'1Qu:.

o

i~. of G'C?' i•ii° -

'rCU C .

.u-0.

:

•- .

rior:

- . ~ t his Gor~,--load 1e,re1 do,.r :( d~srzgar d t=ttigue)

,

: _ - - C

unabLe to yCUr usuaL .:o :-'.:

1

act _•r'_,, : o : L ° _ c 7

oc__iz .. . .o,., sc~oo'_ .:c : , c_ hcus_-_o

~- a, ho~:i_ _ i. )~
p.16

~~~ ~`~ y

"'~-~-~~~ .~ ~ ~~ ~

i ~ , ~ ~ ~ --

' -- ~~ /~ U ~ .1 ~ t.-

1~- O~ ~ ^ .l . ~ • V ` ~~~ ~ . ~

~ Lj-~~_~,~~ _ : ~ _ = ~ =~= ,

.-~i-~ ~f~' C _ C =3 3 = _ ` ` c <

.Cil. .l~. :~~C"

_ ~ 1- i-

~J G_ C: C.~ - ~C G ~ -

. ~- - ^ I '- C; C.:

~=_~~ll~ G~=-_r~_~__`_~

^Q _ C C ~ C ~; r

-.7 n (`- _ ~. C _. ~ C• ~ t- r - ~ __ . _ r

i = :__ ._ . ~ } G =~ c `! G~ ~ ' : ~ ~ Ul = trl C :' v_ -

t n=`___G LG== :YC"= .

~ ^ ~•

_ >` - x r :< ^ I :c _ c ~ c c _ . .-. ~ ~- ~_ r• ~ ' ~- ~_ I r ~ ~ ~ - ~

_

I ~~U`= ~ J,~ f ~/ j~ j j/~

~~J~ .~~ ~ ~, ~ j~ j,, f ~

5~~~

QR 1

;~~~~,

:7 a ~'~~~i~~

_, . S~Y_t

. ..

;~~~ ~ ~ ~~ i

~ I

~ j ~~/ ~ l 1

.~1~?_~ `r'~~O A R ' / ~ ~' -^ ~ " ~

(Or ffO?°SL:IESS) ~ J~ ~ ~~ J ~i ~ ~ ~ ~

~_~~.__~~~~ G : ~~~_{-== ~~ I ~ I i~~~ ' f 1 I

i i l~~ 1

y ~_~r ~. ~ ; ~~~s ~~~~ - - -- _ ~~~~~~~~=G4 ~ ~~ ,~ ~~ jtJ /~ i~~ ~G ~~- lrJ

N~_ . ._ :~G ~ / ~ ~ f / ! ~ ~ j ~ I ~

--v_.

. _l._rrliy'n~

:. .., ~

' f l j j J 'l / / ~ J

- =___~ _ ~ 1 ~ / i / / ~ % i ~ ~ ~

- .o~,~,~~ ~ ~ vo -~ __J ~ ~-- ~ ~ ~ / / ~ / ', ~ / ~ % ~ 1

, _ ~ _ ' `i ~. ,~"

.'~y j ~ _ _mw_~/~ ~`T ~ ~~ ~~ ~~ p , / ~~ ~

l

~ ~- l ( i

trrt--- .. ~

. ____- .._._- __.__ - _._ __``_•~_-__- _____- _

- :. . . J _ '.f _ ^ ~ .( ~ ~ --

( _iJ :' ~ I I

:2= 52'rz'_"?_

~__~ L~~i'is~ ~ Q! _`_

QO(1= 5 ~ ~

. .~=C :. 1

_Q ~ :Z~r C=U52 ~C~1 tJ :

.o ~ _-. ~

l7°_C'°°c2 OCLLOaz~ oC L'°='-°O~`.Lpi??1 ZC~='r'_- . (:LS~.

~ T i° 2Gd : 10C1c= Q 2'1 C3C'Ou __,'~r

D2 t17Z0~ _`O C`'_O ~ 7~ ~~' ~t1:3 2~O11~~. Oi ~.-J=-`•: ~`,7? rOC C^11=G =0~- --'

Ce_ :a r

T :.i_~ t :~ s uot- o~c L_'r~_ do~-,.(d~ sre~~_ .~ __ _~ ) r

_ ~Z llCl°D! _ ~`.J C_?'_'_'O :'~ . 'rCl1= Ltsll2~ ~O :' ., cC~_'r_ Q" ~~~r=- ~t -- _

.'C'-'- .

, ( OC~ ~~ _O~ . ~ _C ._CC ~ ~~. . ." C • _ ~ ..--- ~:] :.li°__ ._ .-, ~ _ _ .,. ~--= `

~. ~ - `_ . .~. .. ._ ~ __ ._ . ~ .., ~ _ ~ __ ._ ~ _ .:_ ~ _ _ ..

. ,

:~ l

.._

- 'T : ." _ . ~ ~ - . ~ - - - - -•
p. 17

bo

~-- r .

GROUP

SUBJECT NO . /06'0

CORD . c f- ~ ~ra

SCORT :ZG a.

c z cn m cn x

1= :ON- 20=. :ODE3"-~L G7 ~- C. -' -

5 =•'_'a I-CS 30= 3 c,7E : E ca c c a: cr

E_ ^ ~ C ~

. c rr~ z

, ^~ = x r. x t_ x k

10= T 1D 4 0= T ?IC~_ . = c ~ c o ==- ~ e: = c c ^- c a a

coUG a

.S F JmUt'1

/

SUSST°3^t4L SORENES S

OR A VaR E .tES3

SORE 'i H RO A `i

S-COR".'^fESo OF SR E A

VAS :__ ~_SC :•-'_?G?,~ ~ ~ ~~ ~~ ~

lo COIVC E S~ =0fii ~

W i1 :. E v1~L~1

R?STRLC" 7(DLIT TI____

mr G ~ ~

a"AD ^C :: E

: Fo ff m ; L : N o y S

_ .. .~ r R ~_Tm_~,~ ~ ~'~ ~ h~ ✓ ✓ h/

~✓

0"•' :~R SY :?D'"OMS I

~LtST? ' 1

sy~~toms & d :_~oca : o

s t e d se"; e r al aou-~ ,

u'_c t :°r cause you to :

r- er t o ?.-n )

1 Take addit-onal medicatio n

3e uc~bLe to o'-_c ._ the ax_•-u anounz o= c .'t t . .a rou cne . . .•a'

per : o :- --1

,_ .- _

c c _ 2a : : . ,

._ . . c _
l,( p

. 18 1 \

A m r =~ ^ L `

. J tT J.7 .

C r ---

~- G 1 C 0 01 7 YG c z a~ a: r c;

1= 21 C NE 20=MOD=' 101 ^'-` 1 m

='=?"C'~ C C E- 5 30=Sc:V u3j c c: r s m U2 cr c ~: a: U0 = M -7 L D 40 = 7 VC?0 .

c

O crcH

P

U`t'Uu

'e C7

U3s T :IIrt AL SORENESS l J I / / / J / I /

R AWARENESS l /

D?E Qno O -_`^

o r OA. ., T' :jLS J )

QL`.i='lh,Sj OF E 0

1SsL• D I SCu?~G ~

D KGEG T , a N

_ 7-~~us NG

-

:S^' 'L'=G717,'I-,:-s/

sT~_C^ ~ o~v

C: _, Q V TAJ V0

f~ ~ ~~0~

_~3 S :'_!O^C ;~S f I

~ ) ( J+ -1: T_

' 7 n 1 . o an s tL

~ several hours,

they cause you to :

r to A - E )

Decrease o p tional or recreational activity L :st

Take additional medicatio n

Be unable to perform t :e na.cimum amount o~ ~o :ti that you could norzaliI

perform

Turn thi s. ucr?cload level do .rn(disregar d iau_Y -,e )

Be unable to DZr'or m your usual vorlL- zc t~ ,_ t'r or le,/el of DroauC

( " O C ~ 1 D a ~ 1~ Cl , S C : O O ~ ~ C - . C _ - .. i C a l ^Cu s,. ._ !_ G ll w_°_ s )

~ i. a :r at i7 v .. . _

I-- - --- ~---- --_ _ _ . .
P. 19

U 3 JN ^~ o 6_0

D ~ ^~

COND .

;- ` ,_ c c

1=NONE

l r- 7~ ~

. z z

3 C 0 R yG r~ co r- x ¢ - -

20=ODM~~y ~ -!I- c

5 =1aA C Z 3 O=S C.v L "s, i, G ~_Z- U] fa v~ -

_0 = 1 1D L0= i NC I? .

P4

P-Z

: O U GIT

F

u`r'U M

U3S TyRYAL SOR E I EE SS

ke

R AWARENESS 10

ORE TRRO^- T

or fiOARSc,NES S

cORT"TESS 0 7 L~~='`_'= I

D /<1 /-

A.Sr_L• DISCHARGE /

_:,E 4 Zi:r G C

0

Lo

S

STqCT(3 _y*~~~/

= .-il

~ -,

. 0 I 1

E

(~!Sm) -'

.~ ~

'•_Z L a ¢is & a 15C ., . =0i-

_ several hour s

t ,. e_r cause you to

r to k -n )

Decrease ooticr_a1 or recreational activit•f Lis t

Take additional medicatio n

B e unable to D er LoL••?' the ^. .a : im llC1 amount of 4'J?-

'

:

that You could

Co'_"

:z

a~ ~ ;f

per-form

Turn this uor :_oac leve l, a o w n(disregard f _~ ti z ue)

C' C ~'-• :( Be unable to C?'• :O r

.i your usual vo" .t1 ac .`.L'r : t-f or Level of 7c L• ^,

( 1 occu c a t ion, sc~oo~•.:o :- :, c- : ic~~ hous~^ .^. 1 a dut L °s )

S . - r at ho. -Z_ c l o s e

v-= -J' = -

~Ic
-

. - ~ l ~ ~ ~`~`~. \ ~~ ~ lif •'"~--

p. 20

GROUP

SUBJECT NO . . _

DATE o w ~

F w

:a

~; L C7 z z

COND . rs ,

F-.

SCORING a rs z m co co

1=NONE 20="fODER4TE Cf) C-)

5=TRACE 30=SEVERE w cx o

. c G

.-: C-~

; F ~E- E c E m co w rCn o w co rr F 10=MILD 4 O=INCAP . W

~ w c>~ w cc w w rz

X H x w x w x a4

pa a,o

COUG

H SPUTUM ` 1 ~ I 1 1 / I I

SUBSTERNAL SORENES S

OR AWARENESS 1 t J / / `

SO^E, THROAT

(or HOARSENESS) I Yh Q 1 (

SHORTNESS OF BREAT

;~L % H NASAL DISCEA?'

CONGESTION 1 '

✓ Ti,

WHEEZING

1 1 ~ (

CHEST

RESTpiCTION f-j

TIGHT,: -- C /

FATIGU E

HEADACHE `

FRONTAL : NO YES

EY E IRR ITAT IC : \~ ~ 1 l 1 I ~ ~ ~ \ 1

OTHER SYMPTOM S

(LIST)

svmptoms & discom°ort

_asted several hours,

-w ould they cause you to :

~Reier to A-H )

A . Decrease c ::-ional or recreational activity List

B . Take addit_cr.al medicatio n

C . Be unable to per*or_ t',-Ie m aximum amount of .:cr?c that you could r.or:~=ai=v

Derior: n

D . Turn t h - ~---ioac _e ,.__ dc :,__(d -4 s- _ar .. =a ., _ )e

_ •

Be

o c ..u 7 13 z . 5 _ _ G 0 1, ^,- u - ~ C - - ~ _ ry C .
p. 21

_ -, . S v -

_~_. _d G ~~~ %

(0,

c

c^ LIED .

ScG a _ N C

?-:~GIT :_GG_~n V

.r. ~

Z7 --

L o `-f=!.•~ LL'=! :iC• _ . ~?~ f- X r ie - f ~t ~~ - C -

COUGH

S2J",

Su3S i~

u /

.',Y!_L SG

✓

~ /~ ~

: _:~~~ :, ~~ ~ ~ ✓ ~ _ _

S o ? '7' ii:G"-`t'

(or E GF_?S7 ;rLSS

5e0c~='_i~S~ O :

y1st_ ~~~~~ ==~=~

cc :zc~=G :y 1 0 10 ~0 10 1/0 1/0

~r ~~~~ Yl c

Y =S °_C"'G :Y ( ! ' ~ ~ ~ , , ( (

7777 . ~I 1 I I~ I ~ ~ ~

t_ C7 7

: ~o :~•= =~ : :zo --s , I

mr { ~_ .:~ .~ J_ .•i=r,'vi•fv 1 ~ 111 J ~ _ !

z

? a tze .r c ause you to :

==* to •A -3 )

~ Qec :_~se ootioaal o r

Ta~_ add? t? aaa? aiz•ii c=t io a

Be LtIIZO l ° to D e : =OL =i the Q a _=uII 2 =OlL O f GJr that you C :

:u-Q C-O_ -

per for=

Tura tiis tiOr ~cl OaG L ='r e !

'r

Be uaaole to oer :o ; ~ your usual cro : zi act'~r? t, or L_~re' oi o :oc,cti'r-~

(i OC017Z ..i0i.~ C10usz! ^o L Qll : _

'r, ,- . - S _ . .

- j ' - -
p. 22

Z,

~~~-~

1060

c ~

SCC ~-,.C r c~ z m r _ , _ x c~ ~

OiF= 2^ :r` D ? c; _ C.;

:_-Zz A_C ~

L0=`.`___C C :C =_

C aUG_

l e 1b Il

SUL

- ( ,

:-:a _- JV . ._:'a- . { f) ~

1/01/ 0

o R ~ 1 I b l b

SO Y=.~'

(o~ Eor=s -

,r~ss )

D 7- E

JYG C :

n .,~~= ~Zb ✓ ` ~

`_~=~`_~__,~~~_ti~ ;~

a_t :__= .

. ; == =,= __~ :'r ~ I l

J-.'f_^~~'f C

~~'1 ~ l.~Q .C. 1G a~ C t .~.• _ C1J'i . /

~e= se-re : 2.1 nau=s ,

~ a ter c z ,sse r^ u ta

A -~ )

oociacaL or re_ :-e at _ona_ L i

~ i~3i, z ZGQL~ :OG2_ 2I~Q'_C°~?O Q

n' ge 11II~0~ ~ .~.0 DZ : :O :m the LZ° ~' =l2CS Z~OIIR t O Tau could

O~ : ~oC : \

a T1;Q t :'_5 vac-S.L o3G Le 're :

Be t10.30! t o :- :0 : _rOtt :- ll512. L VO ::tj ZCt_7= t 'r or 1_`reL o : Pro G'1C~1'r-

(i OC_ Ja 0 . ., s C :00? C'. CI:- _

S~~.r

'! - - -

f -' _ - .
o ~ ~LU S~`

p. 23

. SMW_ . . T NO . _

D AM

CO~;~ r I r _ c C

~ CO7

-

7 C K G'1 G.

1- 10 !'

:t'~

5=TRACE 3 0 =~- -- _5 L ( ~. E M

: _ " - ~- ` - _

U;

?0-M ;-,D WI :vC '-° .

- -

COUGH

3 PUTUM _ _ _

~u3sTlaN1i. SORENESS

OR AWARENES S

y~ri~or~S^ ~ zsS ) ,~" /d )o )o ~n I D

_ _ . ~ C ~ i m ~ l `. . C. J O : 3

7_~1r" - - J' 0

-ZEST TCH-ns : /

-=- R _ C rt_ O N

-- ON -, L : vo YZs

I s

__

- _ i I

.T~ m

-

T_ ` =

._L O ll

7

_~- E ;? S71fP ^O ~,w I •

/~'1~ ~ ~~ jj`~~ MST) („}~,~ yj~~

ti several hours ,

- they cause you to :

to j - E )

Decrease optional or recreational activity List

Take additional Medicatio n

Be unable to perform the ma:C? m uu amount of G'o : i that you could nOC .rall j

perform

Tura this workload level doGz(di sregvrd fatigue) .

Be unable to perform your usual v or Y ' activity or Le'r° l of nroducti T itJ

P occupation, sC .oo L +ott, critical hous°^O 1Q duties )

stay at ho=_ s__ .-(Loss s_c~_ t_ ., ._ t~cc. -o- ._)

Visit your physic _ _ 1

V ---- -• =nryoncy ._ . . .
p. 24

U

^ ^

D 1

-

T- :

'

CCND ~ = - - - _ _

S~ C ;',__T C

?TO N E 2C=__CD=~^`- - c = cr C-: c,

~=_On_C++ ~O=~G!^7- r_ ,.• _ ` ~ ` ^_ ~ C 1 C=Z

1 0 _`•~ ~.D Cr.

CCUG =

S 2UmrM

0asij 3,-z7Ea<v1 :,, sc : =S s

1=-3 °:I S S

SC R ? TE30 ^

(or E0A°S~Y~SS)

S~C c.S 0= k5

HJL

'N' t F . D I'S C LL_ =- C- 7- ~ 1 ~

oc -_ =a :T I ~ I )

l ( ! f '' ~ ~ (

`ri=-~ ~ .._cI C

7

7:~

y

-C

r~ L30HPHHH 1 HL5L/

=-~ A C-

:

-:1 0 :T

-° vo

Y E r ..•r.r t

_^ 7 0 a

~_-=~ s•=~.f~~0~,<S 1 I I /

J J

_ ( ~ T )

~

s T:7 1. .')QS 3c Q15`^, Z :O :, /

, Z !a s e'r e Y a I hours )

Ld taer cause ycu to :

= a r t o A-a )

Decrease optional or recreational act i •r~t r

~a~e addit :onal mei i c a tion ^ai?f

, 5e unaole to oe_ orm tae ,ma•c .mum aaouat o :o r _ . t.a= •rou cculc cor . -

Tura

De :Iot'

t

m -

h is vor'c 1oac level do v z(d._s r e g ar d i 1 t' -'-)

d

„c - ;

Be uaaoLe to oe-_or~. your usual vo ;- :_s act_r?- o^ ~ e`rs? o prc

d~s---

ti- St a~ as co~_ = r' s =_~ : . =_-_ f7

- _s - =ro U

- ~ - - - ' - - - - - - - - - - - _ .. .
p. 25

GROUP

SUB jECT NO . 106 1 • ~

DATE ~

COND .

E• C

cc H 'H- ,~ z z r, ~

H C=7 C Gr? E- .~ ~ r-.

SCORING m H co <

1= :dONE 20= M ODERTE `n E" c c c -

)

o c a E- c~ F c~ E- 5 RAC E =T30=SEVE :E a. w U, G M W Cn c w Cn cc l0=M ILD liO=INC 4_° . x y` w x w x ra ~ ~ o

ca e~ cc r~ cr ca c~ a a, ~.

COUGH

l o

/-~

SPUTUM

SUBSTERNAL SORENESS

1t~ h l 1 (

OR AWARENES S

SORE THROAT

( or ::v ADSi. :: .t.SS ' )

SHORTNESS OF BREACH . ~II

NAS A-7, DISCi'.=GE %

CONGEST=ON •

WHEEZING

I ~ l

CHEST TIGH"'"7 7 SS ~

RESTRICTION

: ?.TTGJF

HEADACH

.L E FRONT? : NO YE

S EYE IRRITATIO

N OTHER SYMPTOM S

(LIST)

: symptoms & di scorafort

asted se v eral hours,

ou d tae y cause v o u to

H e :er to A -n )

n . Decrease on~ional or recreational activity List

~ Take additio U . : :al medicatio n

C . Be unable to per=o= the maximum amount of work that you could nornallY

perform

D . Turn t- s wc-'.-.ioa- L_•re_ cic .:nld :s _ea- .: :sz _Ese )

Sc a'-- I or _- -2_

( c c c a-- I , S c

c- c--~ ._ ..-C_ . C

~ . -a ` . . :
~ p.26

i'-:---

'0 UD .

1ONE

6

i O 1

°% IN °2tv ~

G1

z

.

H H

M H G7 H }~ E

20 H

=MOD E FIATE C0 H C.)

5=TRACE 3 0= S c.V r, q E E c c-~a cr2 c~ E-` E &- C

0=•`_~ILD 4 0=1?ICA P . c x H x ~ X Co X `n o r=2. Ca CO

° '

O U G i3 ~5I

PUTUM

J3ST E °NAL SO R ENES S

R AW ARENESS l ► I ~ f ~ l ~ / ~

ORE THROA T

or HOARSENESS )

~ I I I

=ORTNESS OF BREATH

( j ?SAL DISCRSRGE /

) NGESTION f

LZiNG

c +

_EST TIGHTNESS/

STR_CTIOi1

! ~ ~l

r

7

LrU".

. ~ • I I J ~/ ~ ~

I l

.Oi1TAL

' LACII --

: NO Y ; S

i i I ( j r

-~ TRRTmnmTON , ~ I I 1 ! ~' ' ~ -~

HE":" SYMPTOM

) S (!,1ST

-=toms & discofa r_'or.L

- - - -- -- ----- --- "- ---- -- - _

~^ se `- ----- v eral hours, - -- - - -

they cause you to :

r to .4- E )

Decre a se optional or recreationa l activitr List

Take additional medicatio n

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

perfor m

Turn this crorkload 1eve1 down( disregard fatigue )

Be unable to perform vour usual v or!tl Sci.ivit;r or level of n roducLivit7

( 1 occupation, school-work, critical househo !--; du t i es )

Stay at home s_c ._(lcS_ s__ :. t-., ._ V __._

^ C- _ ": _ , .
p.27

-

GROUP T

SUBJECT NO .

DAT E

COND . / c~ F, r F+ c c z z

SCORING a ~ z cn CO co

<

1=NONE 20=•'rODEP.ATE ~ U

5=TRACE 30=SEVERE ca co ~ C4. C= E' ~ E z o E c

10= M ILD 4 O=INCA° . ' X x

}`

ca X Cn

a a o o

COUGH

( ~ + I l

SPUTUM I ~ I I 1/ ~

SUcSTLRNAL SORENES S

OR AWARENESS

SORE THROAT l l + I

(Cr HOARSENESS

OF BREAT ) SHORTNESS H

:1ASr_L DISCHARGE

CONGESTION J J / ~ ~

/

WHEEZING I ~ l I III

C ::EST T=GdTNESS /

RESTRICTIO N

: A T= G J 7

La

FRONTAL 'HEADACHE \/ ~ )~ ~ / ~ I~ /O I D : NO `iES JO I I

E'f

. iRR=TATToir I I

OTHER Sy?,rpTOME

(LIST)

i s-y_,:

-D toms & di s corn fort

asted severai hours,

ould they cause you to :

=e : to -r )

A'

. Decrease orzicnal or recreational act=~.ri t~r L_s,,~

B . ia :e additic^.sl medicatio n

C . Be u -able to perform t h e max,-mum am ount of work that you could normally

Der : o '_" :1

D . T: ._ . . this w__._oa level dcw-.(d--' :-fe_

.-ar-d

'=la- WC r ac ~v

i

e

c c _ ~ 3 . . C _C ._Jf C .C_ _ .._ ..~_ , .

.~ll S e _C 1
p. 28

wU 7= -._ 0 ~~ j

104

~

D 1m 22 -

C O U0 _= <

I-- ~--4 t-- {--.

1 =`T 011E O 0 !7 _7 n c -

. C = U G ` ^ ` C CC:

-

n r CZ ___ ~ Q = ~ L ! G7 _:

10='

r C!

C L' ^

.

.t . 0 L:O _YC~° . c~

COUCa

S?U'"GM

Su3S'i'E°.Ys L SORENES S

O R

S V FIE lE R V-d-T

(or ROP_°S 7 ;Ic.SS

jcOR'_"_TESo O F

co M c --I S T _o N

~

_ I ! 1 ,I _, G

~__ r

:_y=?= _n_

y

_= -r~ 7-Z -Z , ~ 5 5~J ~ S

l l~ ~ i(I ( 1 __~~~_~J _ -,o :~~~

/

~m^~ (~, 1 :

~1 I I I 1

- : a s di _c c :a 0

z !a several hours,

_d t ze ;r c=us e you to

r t3' 1. - F- )

Dec- _'ase optional o r

7 Take add 1 t 'oC12 l- ul ed '_C° t i0ii

Be uP_? bl _, to D e : :O :m tie m 2 : :` .^. .L m 2 .aOlIC t o ; L J : ?L :rGu c^,u_G

perform

Tura t :7 s GG :'!:io a C 12,r 2 _ QOc. z (Q's .e '- ;. . d --.- ?4_ z uz )

Be uazo - _ to oe- = vou: usua

t ker ~c- ;,? C- v o 1 ° r>_

C'- .

. -___ i.G ;_jQC 'd ,I _ _~ !

~ - - - ~ =- - - -- - - . _ - _ _ . .
p. 29

D

cccr~ . ,~ ~ L z < ;. _

~^/ C C r r= - _

1-7 _

= Z Ql C F G~ r SG < - _

1--~ 1-- 1-= F-- ' F-rr-'. ► `;

!=NONE 2O=

~~ ~_.-a ~-c l _~O=~~crL3

_GQ

_ __

D __ a

z

n_`-_ C'' = C C G: L C

10='s D W;=sC"°, ` ~-

: x r x x r a c

COUGH ~ I

SPUTUM

SU3S sE 'NAL 53aE :t=S3 ~ ~ ~ f t I

OR a:Y_"_ a=.Y_ . S a

~ ! i / ` ~ ~ I f 11

SV M TSMAT

(or SOMS E ;IESS ;

SHORTNESS OF L =~_~= ~ ( 1 ~ ~ f In ` f

YA.5 A- L DE sC HLa c_ /

CONGESTIO TCONGESTION ` N

I

WHEEZING

r'^-S' ;-G :"~j ~~ ~ _ ~ ZS

'

RESTRICTIO N

-_____ UE ,> >~1 .I ~ , ,~ ~ ~ < <

=

0Y___~ : 0 f

~- T-=. . ._ RI :~ ~ m -__ _ -.o N

T -

ES•= M

, , =~°u S (__J :, ~ 1 ~ 1 11

: ~~tocis & disco .~_c . .

/

z : several hour s ,

. d ter cause o'a to :

to+ 1.-S ) -

Decrease o?tjznaj or recreational activity List

Take additional medicatio n

Be unable to -'or_ the Mami=um aaount of G-or!ti that you could

nerior .~ .

Turn this uor__oad, level do--=(disreg .:. .rd ict Que )

Be unable to _-- - o . m you r usual_ Go r

, W activity or } e're '- of :3 Guc t

_•r : t

I

(° oc_ . ._o,_, E c__cc_ .:o_ ., =_ : _ c -_ hcus_ ._c _ d c . t __ s 1

Stay an home 2 _ _ . i - .. E _ sick i _ ., . _ _ - _ .. . v c . ._ `-

V _ s _ „ .. , _

- Visit in . ' - . .~ . .
p. 30

1 06 1

D, , T _ I = /D

i.OiYD = u r _ ` _ _ _

SCO'= :.:G

_ X

!=NONE GrO=-_C D -a_ TZ ^~ _ ~- ~ c Y c 2 C c `

~ 5-

-'_R_C Z

1 n=z`__D L Ci=_ :YC A_,~ lam-

~

CO U`_ I I I I

SPUTUM

_ I ~ ~ 1

L , Y,_,`„~,C~7y vSVl---l

_

...

.vv

OR ~ (

SOR

o~ E0~-?Sc

E `^==0"-T

:tEti o

j ~

-=0R"' YMS S OF J«-= ~`~ _ _ oil ~

0 UcE 5 T _O F

- __~_ ZZI yG __ TIGHTNESS /

-= ._C_`-O_Y l l tt : l ~ ~

~1 I __ M _ T.- T _O N

-- :. _ . J _- .~_~~- ~ ---- - ,.t~

MST ) .-~ / 1 l I~ I

several hours ,

they cause you to

_ to ,S-"' )

Decrease oOLicCc ! or r°^_=_-C :Oi?_ activity CL_-

"•_'d :=° additional Q : e •1'_c ' Z i Q n.

Be uIl2.Ci? to perform the 4..? m i .=:u'm amount O ; GJr .; that ould

p er fo r m

"' .a := this c:or'cLo`d 127e1 dow„(d=srega ~_d i_tiZ )

..e unmo! _ to perform ycu : usual o_ ._ ac :-•r : or !_, _' of :rcG-c r= r

(' hc,_.. ._c V is ___---

L - :

visit in 1=nr ;-7 :j
p. 31

o ~(~C~ / ,~ ~ ~-► , ; ,~,4.`~-~ _

C -Q ~D

1=_~0c~i~ 2 0 F)_~ "Z

0 =S a ~ Ul C -

G1 1 - ` ~

C 0U G _

~

U'rUu I 11 ( I I

so :EN-E s -s

3 3 a:; ' 3'''F = ., I ~ ~ 1' 1 f ~ j ~ f

oz- '~'iO 1."S L Ni.SJ )

=~L?m,~~'.~J 0 :

~

ozc~s~~orLLlj_e j

=` - -C^7 () .7q

IJJ ~

~ ;3•_ ._~ . Y~ ~ __~- ~ ~ t I ' ~

_ 7,3 l T

r.-ST

) se-reral hour s

t :e,r cause You to :

to 1.- T )

Dec` .-!?s? ODL1.OCcL O L

Ta :-e zdciiLioaa? me•.i?ca Lo n

J D e _ _o .= t :1 ,~ m ? - ..

.L'^ 2^QII~ Oi v J_ ' .i? r0~ C ..

.U_G S 2 llnZO i _ t

p e

.., , i.~' )

1P .- . ,i'_ s G:O L"~_l03.G ~_ 3

_

z

3e unao to De~i'o . < _<,-cu :- us• , =or' ac t r : o_ ? v~_ c : cuc

ac_ :oo_ _ .--, c _--- a cus~ c ~- . -

r a . . ., ~_ ._~, _ .-
p.32

- .

41

CD .

_ C- C

~/~ ^

C C G- .- ^_ _ = ` - c

.

C 0R ' _TC X r= < -

1 `- -

1 J0 2 0 = ._nD -31 1 c. E- U c: C

5

1 C 7

. ~ G Tl •^ C C=: U1 CC ~.' Crl

10=`.1iLD 0=7 :{C~°, ~~X ~ X X r X ~ ^ c cy

cocrc ^

SPUTUM ( r o ~ ~ ~ Ul

5 ~l 5

3 u3s L E3Nt L s OHEN-E s S

B AV7- SS

o r

O a _ -,T 7E, J 0 "

A

0'tC

Sa

_7 S T

T . D1SO

7 0 :i

.H' s aC~/ ~

E. LU I.rc

. .-. J

ESTH ._ C T I 0 N

L r o /(J r~ ~ ~ !V

~

j J :✓

OYT^-_-:,, NO av

0NN

R S' TO L tS ` '

( L 7 ~ W~ c

"?~i

several

.oms ~t QisC^,rSror

hour s

.L ~~j ~

i they cause you to :

,

. to A _ E )

` • ~--- .

Decrease ooLioazl or re : a~t a e i)`T~il j_r> Lis t

Tae adai tional medic a ti o

Be unable to D e :- form the ma•;imum amount o f

:ror!ti that you coula r_orma> > Y

aeriorm

Turn t h is vorkload le rei doGa(di sregarci fatigue )

Be unable to n e?'LOrZ your usual uor~tl actl`r :tf or le`r°1 o : Dro aL'CL1`r?

( i oc C u j 2 t lo1 , sc h ool'w ort: , c :' _ t 1Ca L (lous e ^o L G Qllt _°_s )

S '. aY at s---Cy: L_ .,,_ _ O u ^O- . w
p. 33

fJ' `4

YD . / •_- a = -

_

0,:17NC

}--

=TQY~' 20='t 50 D

_~,~y c;

-0 iCu 0 =

.s `1~~.~ L3C C1] G7 ~ t!~ C C= -

-

=':ITJ] 40 = 7NL' a-_ 2

~ ~~' "-. L'= L'~ i :! •r--• ~ :._

/y /y /tj r~ j G

9 J`~UA /C)

1(3S iE'N!?L S0 RE Y-E S S

' ~+ C

A °

lC ~Q s

~ 0Ri'T !'.S.D d ^ `: A 99`

2-i 2- Zv ~U

-ef~/ ~~'r~✓ 1~~~~ ~

lsr_ . D T SO :S3C --- /

iG 7STTO Y

z I'iC

, CD z6 f,o

t

5

s c

-I ~ 7

~

(D z u ~ iU 20 -1 U

^- L VO ( c~

}~ L = S `_`_"_^_ 7 0 :i 1 _ _

t 0 GLS'3c Q'_S --t

se~re,~ hau,-s ~

6 6

e r cZuse reu to :

to A - ~r )

)ecrease oDLi0C1 al or recreational zci.1 riL'! j,!St

rake additional Q,e .d ic° ' ioCl

c' unable to ne :" f or'r' the ma :C1^ui1 a iIlouP_ z oi G-J'_'' t ;i? - You C^,u_G

;er iorM

u .u this workload ie , rel do v : ( disregara i~ti3~~e)

?e unable to eer=orl. your usuaL uor',= acti~r=t-r o r

oc pa t 1 c n , scco'_'c .U, c -- '- ~i cus~ ._c 1` ~ .si

a .. c .. ._ __c ..s ' s -t7: . . . _

oou : s_~__
p. 34

LTD .

nn ~} !-- = C r^ ^_ •- _

'

_ -.Y 0 LI c 2 0 ='.t<; D _ A

J

--_anCu _ . . w_ 3 0 s C '! al

- =

=

~:r77. D L0= C~_? c

c

>trca to

UmUx

k-3siEa YA L s0 : =-=j?s s

a-'y^-s a

O

E O A-Ds Z NL 'S 33 ) t I ( ~ j ~ ~ ~ /

1 D :1 TIJ r. .SJ OF O

G i, D I C C a A J~ N /

/

U

T~_ C ^Cr~Y~r~s~,'

~--

-

I'D c r

,'~T :~ Y 0

I AIIs T C X E r

~~IS '" ) f~" P'o~ ~ - f

^to rn s aisc ca _„~ .-

_ several aou_ s ,

taer c z use yeu to : f-~

to A -C )

) ec^ ea se ooticca l or recre a tiona l act ;-,- ; -- ;.'st

_'z "~ acditiona ? me d ic a t i o n

]e Una 01e to z Z - "or= the Py2 ;` .^.. l 1CIl 2. :a ou_^ - O~ w o_ ._ . -' 'rou c^,ul G

3 erZorm

_'u :- : t l ' _ s o T ._~ C3v i z Ve L Qo as ,. e g : . .. i_i.

3e uaaoi _ to : e-• :orm your usua? vo ._ `o . L_,r__ c - oc=c r ; --r

, oc~ s cc! 'c c_ .- . .us .. ..

~ 2 , ,. ., ._ _ _C.

- _ - •. 'r _ ~ _ . ~ - ~ - _ -•
p. 35

:~~ _~ : yc .~~b~ ~' ~ ~'t ~• t'✓

D TP ~

C O rr D

S4C° -- YG C,~p :2(r 7

? = J C NE 2 0 =_: 0 D_c._^_r~

- v n _

3C=5G'!L -.-

_

~' n ~ ~r rn =_ - cn C c= ^ ~ ._

1C=`_= •D LC= aC • =_ x r- x ~' x r= x ^'

r_ _ _. ~

. •--• i=~ ~ •f-'- 'L' az

c 0Uc- , 30 1 Z2 20 c) (d %U

s PU TUR

SJ3S= E°Y` T . S0~ ~V~S ~

A. 3 7 I 0a . :d~ :

1/0 ~O

(U /v t

I ( ~

SI~Y~ m i~vR rts

(or ~0~°Sr Y~SS)

/0 (0 ~~ <v 10 /0

SECR^ NE s S OF to 3c) 12-6 //-d (a lC~ /

o /0

y ASr'_i_. D Siu??C~~ / ~

Corre 7S T _1- C ;r ,v 20 ~0 3G -~, ~~ (v f ✓ r

U

Mc~ .. . .. :iG Q U , ~ l I

ID

C

~

S~-_~_' 2O

~ ~ -

•-==---~ f - ! ~ ' i

C CZ_~_~ : ~o _~ ✓ ~ /U j ~ ~ ~ ~ ~ S

,~~ .i .. J _~.t_ ^0•`•tS ~ - /~

sy~~to~s ~ H- Q1 :Coa :c .t

-Z= s e 'r2_" al hours

c~ ~-,11 IJ _d. t-e .r c_use you to :

d _ ,~7 )

Dec _ a se oociona_ or r~c~__tioaa_ actir? G±s C~

3 '.-- ° a- Qai t=0[7 a L L1c2i1iC°i.=o[1

I ' - 1 l r1g2 11R2..~ ~ ° O D e :• :

..

Oi' t7° _ l.l . ZmO l.1i z -1 - 'roil C•.~-

,

-

1 o - G C *' ::: 3

n e :

~i

D T::_ :1 t

'l is -or!!oac 1e're1 ao ;a(a_sra

Be L'C!2.0 L,~ to D e ^O :m fCII : ll51'.1 v0 : :LS ac-, t% or 1°'r°= '

OCC_,._„C~ C__~_C__ i.CllS~ ._C L ._

S .,-"r z_ ~ _~ ._ ~ ~~ - - . .. . "O ~~ ~ ~ ~ : Z '`lI ~ ~~✓;

~ - _ -

. ~

. _ ._ - - _ _ - •

. -~ „ v 1~_ -~~J {~

,~_ .~
p. 36

z u,:

C O ND

.

p L (Z SCORING a~ 7 C C Z Ct] G: G. f X C C

~'• C., f--~ F- }- S- i-^ }-= r=' -- ~; G:

-~ n n 1- = C = L c'r C E- C ~ ~ - = r 5 -' : :•: C E } O = `J '1 u _. =-' ►. ~. C== LI} CO C C=: Cr:

1 0 ='d T T_ ~D L 0- T _iC ~_" D . X

:OUC a

01 1 1016 D

i ? il "_' (7 M 5

>ii2 S~+_' Z.°.Y-`-±, SC~ -EN E' SS

j*R a:Y A3Eil_. S S

Q?

. E

fiop~s Er EE SS ) I I ~ J-~ 5~ f 6 S l ly S

_ORR N r~ /l .J Or

(V 5

A-SA_ T- DISCHARGE /

O i~IG c S'~ TO ti

L I

E E ~ . ciC 1/0

_^¢n r. .~n _r

.~~~ _- .. _ :,J J 1

c1 0 .4 t?

:___ ~ 1 ~ ► ~ ~ ~ ~ ~ ~ / I

~

o,;C s ~ 1 1

( t

l i • i J .r' ) ~

Q 1_

-

iaey c

several

a use

hours,

you to : `r

to A-7 )

Decrease oDLlonzl or recreational activitV L i-St

Tzca_t =or.a1 med i c ati o n

Be unable to oe_ =or-m the ma :: ; wum amoun t of that you could rcr __y

oer*orm

Turn t a i s GoT• kl 08.C leve l Qo v l ( a ? sre3crQ i3i.l g ue )

B e unZOl e t o De'_'_or u y ollr uslu2l vOr :l activity or !° ,

f°1 of rrOallC t 1`( i- T

~ l occupation, SC C :'_ z 1C31 I10us e^O 1C. CL' ~_ °s )

c . . = Y at i O :;; _ s _ C ; , ' C s e _ _ c L _ . ., .. ., m = C ~`

vol:- . ~ _ ... _c. ;?

~---_ ___--- -• _Ci~,
p. 37

(D b~

-~ =- --

ff D

S :.7i T_uC ~~ ~ C

-"- <. G: . G: - :G •C G G

C; 1__• ,•- _ _ -

-_tiQ ::_. C. L; ^_ •-.

~_7 ! C_

.--

c-1

/"•' C' _

1 0._•f ~ r ~_vl.,.' ~ X i F _ 4%< ^ ;~ ^ :c ._ _ ^ C v ~

c =

SU3SL ::~'~S.i• 5~ ::_'.i_ .~,. ~

( a r

SORE TEF.Od- T

E 0?_ RS N E~ C S

F--,-r7s s o= ~~=A_~ ~

:CZC - " 1- 0 :~ AD

~ l ~ ~ ~( l ►

_S 7

. = c

i i __- i

- va . . ~ ~

~~ T :~_•~,_~ a :I I `~ ~ ~ ~J 5 ~ ~ ~ ~ ~ ~

_ ~1: ta a s C LL S

z= se^re .a} CIO u=s ,

t?-l

`q^ C a 1 c e- 'r c ti

t 0 : I

t o

m

L a cQC.

i C ^ - - = 1 1f

v .711 C .

.L_C "•,.-.

32 ua`O i ° to O°- - v .'"' i, :~ :~ za :----=u:n

Dz'_'_0 C- .:

Tura this vork' oac 1 z~ 're_ do=,~(d s . ~ Cat !2 )

Be u(1Z Q 1_ to .^.?•- ,,.l'_ c ;1? t 0 C - t °

.r ° C=

OC 2 a Z: _OC , C'-C)0 _ .. c '. ~ - - -' r--

..C. ~ - a 0 ~.

r-=-- -- ---- - -
p. 38

D

~~

'~

FD

44 _ _ = =

v v a _uC'. G

'}

0 I

1 = :i0 ::u 2 C- .-r' • _ "

D E n_~_ C' ~% ` L• r C: _ ^_ C. ~-- `

.

Cu ~0=•~G`~ _~~ C c 5-~ : rn

? Q='•iTi.] LL?= ; :vC n~

-_ X~ 7C r ~ U] X C!1 C - C ~ V

- '^ ►-- ~ . . ~ r. ^

.

7- 0 uc:-:7

S 2 J*_'GM

5

`~ J y S , ~ ~ ~ 1 S

SG3S~~~:i ~_~• S0 : ~ :r~ : ~

a::•'-_~=lf ~SS I ~ ( ~ LJ ~ L f ~ ~ ~ ~ ~/

nr0 A •_°,S~ I Sj)

-7r, a_~r~s ; ~ I f I

7.c~~~

rSG El ST=O -N-

; CC T 7 .-1 _~

_ TO + ! ~, ~ I I ! 0

-r _ ~ 1/0

= =' s T T~ ~ E 41

- ~ocas ai_c~=~ 0 . .'

s a,re- =- na u- = ~. ~ ! - ~ / ✓ ~

C?tise you t o

~J A -H- )

1?C °~c` 0041~~G~ or Z'°C . _° t 1oi7zl 2,C 1'r 1 T (

ac.citiona_ mc?tioa ~ ^ or- > > j

~e L17`0 , to D? 7 =0 ;~ t i ma ; I :U.iIl 2_ m OIIII t O : t:i-C ?

rOt1 COl'_- G --

a

~sru t :i s c o :'.r_oac Le`rei ao disr e ~ i a tu° ~ ci )

C : c CQ1CC r

~e uaco?_ to i,'--0 ; : vOu- usual Go : ._ acCi`,-'_ o- 1_r° =

CC ? OC _ OO~ Q_ . C_ _GLC- L L o II C t _°-c

~ ~ ` S _ _ ." - 0 _ `.; _ .;:`_' E _ ,`
p. 39

So2

~-- """tttfff C

C OUD

S :O

1

a

N0

YG

a 7- 20=:£ 0 '_;?

v ^ _ . . ` - C

:.r

_

5 '__"-_C 30S ZT~az.

-i.rT ~= n

_ D x `- ~ :~• x C

c' C

10- L C N C ~- • ^ _ x

c e: rz c :-.- ~ ~ _ ~

CCUC= /O

SPUTUM

SU3S T ?'Y 3 L SO =: z 't-. S C

O R

5~~~~ Tl~a0^_ ^

(or ~OF_•°.S?Yc.SS ) I, d

SEC R .:.

~J-

~er .

;ZG _ _ ~j

r` ~~-7 ~ / `J ~/ ~ 7 ' ✓ S

COKGSTOY

r~ .~ . -7 nc

=~a_•r_~~- :~ro __s r ~ 1 ~ ~ J ) f ) ,~ 5 _'D

C) ~ 5 ~ / #

: `nv i•{ J _ tJr ffl I j ~ `

~2= Sz7e•-'_1 ~lol1T_'s ~ / . ~ / ~ / ~ ✓

?d taer czuse you to :

- ° tJ

Dec-ease 7 1 or a

~-i onn i-r i~ ri

, on~ onz_ r°_,-~ _ .

-o

_ .__ z l n_~ - G_sv

Ta1` additional cm e di =cat~o a

oe : :o : the ma :,, = um a_ouct Of 4or'.ti t':=_ . Be unaoLe . ycu ccu?c r_cr- t o

~ oe :- ior~

Tura this cror' Loac L'_,re 1

Be uaaole to nz- :o :m VOU= usuz? vo activity or Le r°_ o

~rcuc

(= oc_ .:oat ioc:, sc'-_ooL .c ; c-_~ica Fousz~^o L_ cu__ )

Star z_ Yo ._ __~ .= .' ..s . s_C .= t_ .._ f -_.. .

- tl_ .'

I _ - - 7 _ . .. .
Lr

C:~u~ . cv c- s- t t - ~- y -} J SC

t c- cn cn cn x : t t a: ~

r F= r F- CV F- cTl ~ t I C L

:L,1~ i(1=_.T~`L1~ ^~ c? U C: c _ 1 t U Q=~ i= ;C~~ L, 2:

r-

~= y L ~ C =: C! <I L Cn c t( l :- C~ C! - cr- 7 V

~ ., r- c c ~

.-r_. .. "

~~~ 1 1 1 /~.J-~\t~

1 ~• ~_ ~.I r- t t O 1=?r .

J

VE=,

L

'S S'l 2_ Li~,_ .••. ~ \ _ ~-` 7 c'• --- , ~ ~ I t tt

C7 `~-_-----

(01/0

l, ~, ~ I It, 1 l ;^.,

~, L ~Z - ---_

iv 0 /0/ti i0 OW. ~~i~ ~

/p} ~ ; ~ ► ~~ i0 ► ~ I i Li ~ 16 =_- ~~- '

---- -_v~ f t

_.T- _

-_ __-_ __, • ~ : ~ ~ ; , , ; , < < , , ~ :

;---- -ti-=--•~ y , t i , ~

~ ; Itt

,, (~. I 01-51 01 51 V

. 31 ►

= 5-V ~

~-1 L I Q~ t t e :tc

$C J~ . ---r--~ IiCL:is, ✓ ,

.~ .~'-. •~; I-J-~--

c L hey cause ycu t,t (

= Le'-=m oot=cT1E-:1 or ra''~a c'_cP~_:, cc t:iVLtT T lst t~~ 1b 5z,

3 . Talk-` ac~J `cn,= ?.

Be ts:._ble to prerorm t_n e mGcri-m =ctmt of work t:n.at ycu could r.ozmal? y pe=--or~

D . Tura this w~r:c?ce,a level cc-N:i (aisr=?=rd f~:r ;~.~e )

_ Be =.=- .Le to perform your us'.4l wark activit.T or level of procictiv? ty

( ccz-.maticr., sc^COI*.v5r:c, c~ r~c?~ hcus2_^_oIC QLICes)

- Stay ac hcm sick (lose s cc •T=•A f=-cm G~r:c)

_

V;s1= vcL cc;,s'c '-1

Vs i :: rc=
p)

'-Kcvp 02

SO~.,~ECT J .1LOZS

D?_ ._'r"" .a' - 7 ._-, r r Borg

~ ~ E:~er-.QP COND .

O .Z ^ N c''1 Sc

=-

.c. -1-MICC!l

~ F ~ `1

' `'' ~ t r~ ~ 0=~7otzin1

5=?"Z-CE Cr) Cl)

c CJ at ^~v t=- F- cn

iJ15=0 :e

S~u~

COM-1 _ ~~ ~ 1 ~ ~~~ ► ~~~~~~~r ~~~ •~ ~ ~~ V~ ~~ 1i .~t

12= L ig; , t

C'c

-

(~_

_ L

_

V ~ C7

NT =7

_ ---

10

i 9/~

l

i

C-~

z

llJ, ~-ri

:

FS"C==C~ : ~ ~ ~ •

.1

--

~_~-,_ ; . ~ ~. ,

I= &

as~~ s2v~a? hot~. 7

w~uld they c:--ii e yc,- to /rtr/

A. De,-e_z- s2 optiona or recre=tior.al ac-~jvitv List

3 . Take adoittonat redic.ation

C . Be unable to preform t:-~e mav ~~ - rnnZt of war'-k that-- you could nor-nail 1y perform

D . TU= this wor_tLcad level aaw'- ~ reQazd fatig.ie)

E. Be tmaDle to Perform Your usual work activity or 1e-.re1 of productivity

* oc"mat_on, sc=:colwor'_c, 'house!--old aut;es)

St:---v at hcme sic: (Icsz si(: ~c from u,-c r'_c)

Visit vcur Fn,TSic-' ~n

i - Vi

s i.t an eT'°,-?er

c:- r^cTl
~ .. .~ ~ q. 42

l ! !~ !

" Borz

~D EM~~, cn

CQM . rp ? , ~! ! r= 4 c") }-Z- 1 L~'_ r~' scale

►- ~'-

cn cn CO x t{,¢ ~ ~%'

r F= r F-- N F-= cr) ~ t{ 0-3\7

. 20"~SDE ^ "-- c 0 NGD,r .~ c~

,

,

1! L`~=r~

_~ E" E~

L~ E~ ~ v] cn crl C i{ ~ tr} v7

-~- 3 Q ~ --'~ n f- •- .~r..'I~~% ~

.' C=-

t ~ P. U]

T Q_,~-=D Q r E NZ Q 5= !e _~-y, VE'-y

I.i =~2 •

COUIC-N - ~ l r I i I 1 I ~~~„ { iL=2:~t

C,"C .

!

C -___-_ ;

/o' !!, ! ~_-_~-

~~ / • ,!! /

24 10 _~-

,~-

,~ ~

L/O_Jlc=ver-, __---

---

==___•---_'~ ) ! , l f ~ ~ ~ ~ / (

33-=~ = ' f,

l I ~~ j : ~ I i l r ~ I

== _-_-__=- / I I • % ( / / ~ / I ~ I

- __ -~_-- i• , ~.

0 1 3 16 6'1

S =C-5 cL C__~,. =vrr' ~

--«Si.aS Saver- -+

N-ould they cause you to

. -/ .

opt:-cr. I- or re~-~ea tic r.al activity List

3 . Take additional rrp-i -T cat--on

~ . Be unable to preform the u~~~rn~rn amount of work that you could r=ally perform

~ . 'ILsr. t`Lis workload level aoc~ (aisreQard fatima e)

~ . Be unaDle to pe_,=orn your usual work activity or level of produotivit~r

ocz*-mat;on, sc-icol~,Or'-c, critical household duties)

Stay c~. ±:1~,~'.e (lose sick time from GiL7r:O

V=1 DCI'~Slc' .T:

V S ~ ~ W-1 rOCTTl
~ ' ~ ✓ ~ I M SCORE SHEET p • 43

GRO

SUBJECT NO ._Ajj

Borg DATE

,

:::i_

U

Exertion

COND .

r+ N M Scale

SCOL -M

V "' H rl F~-{ ~ ~ t

1=NONE 20--IMODERATE Ca ~ v

M

v ~ H E-4 2 ~ ~ H E a at allg

5=TRACE 30=SEVERE °~ry' .= w~ a cz w 0 0w

10z=40=INCAP . ; 0. S=Very, Very

' . Little

COUGH 0 1 10 0 R), ' 1= Very light sPUM ,~ J

LL

/

2-

-

Light SUBSTER•jAL SORENESS

OR AIqARIINESS ~ J ~ (l

Lj

i /1 LO 3= sbderate

SORi ~AT (~

(or HOARSII~IESS ) I ~ I 4

to

Soa•e ahat

f / Heavy

SHORTNESS OF BRFAIH

~ / ~ ► H 6= ve2Vy

NP-SAL DISCHARGE

/ CONGESTION '/0 7 to 9 0 l 1 Very Heavy

:~-H~~~ ! D I I I 10I zIr~ WD ~~ ~ 10= Ver~y, L y, Ver -HESST TIC~-IZIIESS T /

STRICTION 1/0

Hea

ATT~~~ i~l 11 I ~ ~ ll~0l r ;!I 1 1

---R0N~'~rT : -N0 YES

S) 2, aDNS

(LIST)

30RC =RTZON

SCALE (o-lo) ~ ~. 0A 1

T

Cf symptoms c~ discomfort

Lasted several hours ,

,lould they cause you to 6

9 -

'fi -

Decrease optional or recreational activity List

3 . Take additional medicatio n

Be unable to preform the maxiira m amtmt of work that you could normally perform

~• Turn this workload level down cTisregard fatigue)

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

(~~ occupation, schoolwork, critical household duties )

Stay at home sick ( lose sick time from w'ork)

Visit your physician

Visit an e?-! -erbeP.cy room
J

1p ~ J (

:OUP 02 ~7I + +

TJBJECT NO .

E+ C' i

Borg

~'s C7 C7 EcE'-rtion

p

ND .

r+ cu cn Scale

CORING

W ~-i r-4 H (14 ►-+ cn

=~yDNE 20=`3~DERAZE ~ o Q O=Vo thin~

~

z

~ o~ w c~n M at all =TRACE. 30=Sr V~'~cE ►-+ ~- w ~ c o 0 P'J ' + w w wcn

0=`_LD 40=h-'qCAP . 0 . 5=Very, Very

- OU("~I 6 1 v1 loI lVl 101/0 ( vLittle

I I ~~ I Very light

PUM

2= Light

UBS=9IIAL SO + ~ RE`IESS +

R A '~~~5 3= I-tderate

D

16

Ri 7H=AT

Dr

4 to ~5 =

HOARS'r~~SS) / J/ otr~~ilGt

Heavy

~ORT~tr.SS OF BREa=

I 6= F.ea~~y

~iAI. DISCiiARC-E/ + +

D NG' "r_S'1?0N ! ! I I _ i I ~ 7to9

~~ K/` Very Heavy

6ilii1 ' 0 I 10= Very, Very

-:EST TT~SS/ Heavy

==-ON

,-TI~~

~a D2C=

~ONTIAL : NU YEE

-TLTION

15 1 52

I

i

I

ST

)

JRG E=ON

3

:ALE

---------

(0-10) 1"7 0 o o6 . JOc)'

= syurotoms & discomfort

a ted several hours ,

;uld they cause you to

-~ +► ~ i

Decrease optional or recreational activity Lis t

Take additional medication

Be unable to preform the maxLrrn,m amLmt of work that you could normally perform

Turn this workload level owE~isre~ard fatigue)

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

('` occupation, schoolwork, critical household duties)

Stay at home sick (lose sick time from work)

Visit your physician , Vis i~ an eme_,-oency room
GROUP p

i~ 45

SUBJECT M .

DATE Borg

EYertion

COND .

SCOR~IC' ° CL

.-+ c14 cn Scale

x

1=11~r _ 2o=~JDERAT~ Z

~ U , ~ " u Cr) O=~~TO thing

5=TRACE 30=Sc~IF~E "' Mi "',. c atall

w a. cn

10=M_= 40=!NCAP . 0 . S=Very, Ve_•-y

Little

MUM 1 DI

3PR

6~ l= very li,.41 t

,IJBS=RI'~AT SOR=SS i I,ig~1t

)R 3= ~bderate

:OR~ i~~DAT '

4 to ' 5 or M .. =S) 1 ~ S

Heavy >riORE~ESS OF BRE~ Z

/ 1 6= H~ ?Sa_

T

, D: ES Q 1 7op.E--- /

:OirST=ON 7 to 9= NG Ve,-;a He`vv

ST 'I=-i_TIEi SS/ I

3 10= Very, Very

:,:EST

'ES T. _1 C~'?ON 1)0 DI1 0 1b 2 0'

Heavy

-

'

l A_~~ ^~

' v 1 I '/ I

lo 1 I~ 1C~~101~ {~, Iy l ~

;~'cG ~ ~~T?'ON ' ~ t (

0_1o

1 symntoms

) 1 r7 0 v v lo o l

' 0

& discomfor t

asted several hours

uld they cause you to ~ -- -- , , ,---- -- _ , -o ..

. Decrease optional or recreational activity Lis t

. Take additional medication

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

• T~Irn this workload level ZEivn (3isre-ard fatigue)

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

('` occupation, s choolwork, critical -household duties )

Stay at home sick ( lose sick ti7 e fr u,70,rk)

Visit your physic ian

Visit an c-mer~encv room
p. 46

Mou-p o2'I/ ► , ,

SUBJECT N0 .-~ { +++ Borg

DATE

COND. rr

~ ~ Zi t 2

04 Cr) + t+[J j~4 SC-- °

SCORLVG r-r c== w w w Cf] Cn M r-= cv r= w+~ ~i' O=-Tot1

t

i_n~ i~~r~ 20 `R)D~~r c ~~ F

}-U

: r: c

Cr)

c~ t

a

I

I rT G7 C I, 1 C C

`"

~

5=ZRA= 30=S~.1~c . w c. a• cn

1

0 . 5-:Ie ry , 4e,-;, ,Q✓~.sr~ 40==VCAP .

.

-61 511= Vem7 ~~t

2= Li,=

t,BS7-r-iT•_Ar

3 _

L to -3 =

or

.-~_- {

OF R=- ~=_ 1 I I 1 ~~~ I

.

~~ 06-1

7 to

v .

101 /1, v( `' ► ~/ l EI ~4i 11~1 a= vv, :vv,

_=..,

(Z T '-C-

~T R Ic~oV ~-~ ► 1~ ~~ ~f l~~ ~~ ~~ ;

I_c=~--~ O ti = ,

=

'L:1(:. a- _~ o ) 0 v ~v0{ 4-5 {~Iy

= syarotcros & disc=fort

=5 te

--uld the

:J. several hours,

,r caus e you to

~- f ✓ ~ v/ ~ ✓ / • ~i /

, ,-+~ -'

Decrease optional or recreational activity List

Take additional s:ed_i..cation

Be 1m-ab1e to preform the ma.dna . m emotm.t of work that you could normally perform

R= this work-load level down(di.sregard fatigue)

Be unable to pe_T-form your usual- w~rk activity or leve? of productivity

occ,=ation, schoolwork, cr4.tical household duties)

Stay at home sic'_ (lose sick t 7-e from work) >~~~

Visit your physician

Vi,;4t- an em`roenc,r roam 7,~ ~ C~~ ~.
p. 47

G'-~CUP

SUaTE.r.T m. ~'~

~j Bcr-_-

D°T" 7~ ~/-t~

~ C7ctt ^

w F=~

z

C:Dt~ID . _ .- t o

,-; ~--, ~~

Q '? • E ^t,

i

t ~

SCOR~?G c_.* t t + C:~ = z cn cn cn X: t t¢ =i

cy cri

UNt t U ~J E~ d=~0 Ci1? T=

_ an c n ~..., cn C t t L a] c!:

c_~-`~ 7d=v~V~L. C~c t- t ~c [_ ~ X L: ~t t ^' C C c!

F- C-- v7 _

{ ! t t ,0 .5- 10 -E -L {7 2I ic A 17

Li =, 2

COL-C-1 _ ILI I f I I 101/d. 1~' 1 ,- VeZ7 IL

``'

j

~`~`_ __ _ i~! 11 ll I 1 l{ ~ I 11 ;t,~l (I2= u

C_~{~_ l ~ j ~ t<< I 1 ~-.--._ -. A -

;c-r ~.~~_ =~~~~ ) ( • ( ~ ~ ~ ~ I ` ~_ __ _

-=- ---- -- -°"

c =N

7 _ - 7_~:

- - . ~ -_

cx~~~ ~~ 1 ► ~ 1 I 1

_~-

77,

~_~~`

au S2Ve'_"al 17Ot=3 ,

~~u1d they cause you,' t o

-•~ror s-.. `,;7~ I ~ -~ - .

Decr~s2 ootionp-l or recreatior.al ac----,Lvit-,7 List

_ _ Take ac~tional u-edic.at;on

_- Be unable to praform the Tax~ m-cunt of w-oric that you could normp-11.17 Perform

11=-, t_Szis wor:ctoad level down (aisr_gsrd fat--;g!-l e)

Be unaDie to perform yo= usual work activi.t-T or level of FroaLCtivity

ocz*.mat=on, sc.colc.,-or:c, c~ t=~ hcuseinold du.t--es)

S t` ~r a t hcm.e s=c'_c (lose sick ~~ ~rcm F or'_c) ~'~-•~~

V=Sit an ~a'?°nC:T CC l ✓ '~~~ ~ ~ L 1 ~ \~

-_ ~ L
p. 48.

S~r 1~y1 SCORE SrtEET

~ l

30 ~,'

.

C ROUP

S'JBJECT i~ .~~

DATE 5/7 Borg

, .7 ~ Exertion

CON D .

R= ~ c7 i Scale

SCORING P

1-1-1 i 1 i

P4 v'; ~'~ F--4 N ~ "'

1=~NE 20 tiSJDERATE ~ O=~To

~ ~ mR! o , In En at all 5=TRACE 30=SEVEftE W o 0

p:

.- w~ cz c~ w a o.

10~~D 40=INCAP . 0 . 5=Ve ry , Very

Little

COUGH

l= Very light SPtJTU1 I, 1 ; I I ~

2= Light SUBS=I'TAL SORENES S

OR AWAF q= 3= Moderate

SORT THROAT 4 to: 5 = (or HOAR..SE~'~SS) ~ + f I ~ ~ ~ I~~~ ~ t Sca~v~at

SHORTNESS OF BREATH

I l ( Heavy

6= ::eavy NPc~Z . DISCHARGE/ i

W= LNG Very heav

CONGErSTION 7 to °_

y

J I I ' i I ^ , a=T TIG~iT~~SS/ 10= Ver,Ver .

RESTRICTION

Ieavy

~ ~ I

I

F FATIGUE

Hr `_:

Y-11, s

-T~TION

0IKER SYNF`IbNS k

(LIST)

BORG =TION

SCA.I-1' ( 0-10) ~•~

j~~

If symptoms & disc ~~ ~ort I

lasted several ho~s, ~ ~~

would they cause you to 1 ~~~ ~- J r

47 i ! 1 !I P-r - 1 ] _

A . Decrease optional or recreational activity List

B . Take additional medication

C . Be unable to preform the mp-xi rnnn amount of work that you could normally perform

D . Tl= this workload level c,o~isre~ard fatigue)

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

( * occupation, schoolwork, critical household duties )

F . Stay at home sic:1 (lose sick tir --e from work) J

G . `J-sit yc phvsic~n 1r ~ in /

H . Visit an ~rer~erc~~ rccm
p. 49

-51 ~LSCORE SHEET

GROUP

SUBJECZ 1\0

Borg

DATE Exertion

CON

D.

° Scale

w w w Hif ~

1CiWG 20=` 3JDERATE

1:14 C al v

U)

g w0=Nothin

Cl) cn a cHn o i w c~» M at all

5=TRACE 30=SF V~t~~ o 0w a

l0=>.'~ 40=INCAP . 0 .5=Very,Ver.

Little

COUGH

Very light

SPUT[JM }

2= Light

SUBSTERIAL SORE'iESS

OR ARAK"~'~SS 3=Yoderate

, 1 I

SOREE 'IERUAT 4 to,5 =

(or HOARSENESS) Som~ahat

TOT., Heavy

SHORTNESS OF BREAT~T

1 J iYLDLDilU6=paavv

NA~ DISC~riARGE/ :

CONGESTION 7 to 9 =

V Er7 He~ .r.

10= Very, Ve~-

=T TIG =S/ Heavy

RESTRICTION ~ `

FATIGUE

HEADACHE

FRDNTAL : 1v'0 YES

EYE IRRITATIO N

OTHER S)2,=NS I

(LIST) { „ h t

1- L

SCALE EXERTION

N 0

I

0

If symptoms & discomfort

lasted several hours,

- -- -- •

would they cause you t

r y 1~~

o

_

A . Decrease optional or recreational activity List

B . Take additional medication

C . Be unable to preform the m3xinn.m amount of work that you could normally perform

D . Turn this workload level ~~ddisregard fatigue)

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

( * occupation, schoolwork, critical household duties )

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

G . Visit your phys_cian

H . Visit an errerce ncy roori
p. 50

SYl` IP'"i 0M. SCORE SHEET

GROUP

SUBJECT N0 . Borg

DATE Z/ Exertion

COND . Q! r--I N M Scale

SCORING ' 2 C~lJ LwJ] Cwll ~1

~~ 0--Nothing

20 ~DIIZATE

10L.;

cn. ~ v

-4

v N H M O thi r,g

o at all c~~ ' o

5=TRACE 30=SF VF.E'~E w w w _

10=:%= 40=INCAP .

4 Littl

0 .5Very,Very

e

( I i 'f

COUGH

S

1= Very light

~ ~~ f~ 1+( I ( ;~

2= Light

SUBSTER.I AL SORENESS

OR A14AFUIESS 3=Moderate

! , ,

SORE THROAT 4 to ~S =

(or HOARSENESS) somew=nzt

SHORTNESS OF BRFA'LN Heav

y

;' ~ ; I~~ ► ~ 1 l~r ~~~ 0 ; l~ 6= 'Heavy

NASAL DISCHARGE /

CONGESTION 7 to 9 =

Very Heavy

10= Very, Ver.

RESTRICTIO

=ST TIQTT

N

TNE SS/ Heavy

LCUE

ADn = I Tr ; HE

71~ NTAI : U YES

EYE. IRRITATION

0'L1'_FR SY=NS

(LIST)

BORG EXmTION

SCA.Z.E (0-10) 0 o

If symDtoms & discomfort

las ted several hours , "70 4

uld they cause you to ID

k . Decrease optional or recreational activity List

B . Take additional redication

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

D . Tlzrn this workload level wT disregard fati gue)

E . Be unabTe- to perform your usual work'- ork activity or level of productivitv

(- occupation, schoolwork, critical household duties)

Stay at home sick, (lose sick tir_p- from work)

Visit ycur physic an

Visit = e_rer2encv rocm

l ~~
p.51

GROUP , ,.

S'LiB.JECr No . _Z01

6 DATE , Borg

F:ae_r `-`.ion

COND .

N Cn Scale E5 K

~~RLNG W w

C!] ( ] M '~' ►~

.. .,~ _

z=11ME 20=v_DD~= f:~

r--i H M

0=vat,; ~

c ~ cn rn cn O, 1 t

E H Z H E-+

: cn cn at all 5=TRACE 30=5 F.V~'~E o

Cn

10=%-= 40=UICAP . 0 5 Very,very

Little

~~~ itLH_LL±ULLLLiveryijgt

SuBSLI•laT SOFE! r ~S ,

1~ ~ ~ > > > 2= Light ~

' ~ )R F?qA~IESS ,O I J ~ I ~ ~ ;~~ ~ 3= 'M.-,derate

I ~

:0~. I'c ~D?T ~ / / ~~~ ~ 4to 5

,or H~_F_I=qS)

5-1 Sat_~rTT

TH0~''MESS OF BRE`=I-; I' I I 1, -e'"`VY

i 6= Hza-V7 y

,nNC_FI777OV 7 to9

V e=,7 H°~-=vy

110= Very, Very T T=C:ii~SS/ Feav

y

'c! T= _ON

I

_,,--

-- ~

..-. - --- -

-

- .. ~_>

IORG 7Cv

(o-lo> ~~ ( I I

as ted sev se& di s ccmfor ` symp tcro

ral hc=s,

ould t:~ey caus=e yeu to 11, I

--~ ~,- I 1 1t

. Decrease optional or recreational activity List

Take additional rnedication

Be unable to preform the iraxinn_ua =ci_mt of work that you could normally perform

> . Turn this workload level rlo~,-n aisre-ard fatigue )

Be i:. :ab1e to per--o= vour usual work activity or level of productivity

(* cc"matior_, school-,~rk, critical household duties )

Stay at home sick (lcse sick tt~~ f`-cm work)

Vis_ an =F ~`.

.

;^ ;`c
p. 52

~ L `,;~ v ; r; ,t • 5, ~;. 5-,:.,,. CH SC:'i. u:. r_-.~-..1

GROUP i t t

s-U-&Mc-L m .~ 6 tt

DA2:

Borg

,~ t' t a✓ E=m -' '~an crt t

COND .

t ~r

~✓ r-+ N t•'1 F-+ C.-:

2

f._' r? SCc-l

y • ! t 1

°

1

SCORING ° c= t5 c~ c~ t t ~r 2' cn cn cn xtit

I.=MrIE 2U-`JDE~r.

• c--' ~ r~ r ra cv ,-; cn

~""' C!"'J C.:[ C] U .1 .7 O=~~tL~Tt

~ C: t ~"' F' G' E^ 'L E-+ E-^ L t 11

C t t C= C!~ Cfl 4- ~ c--

5=T-RA_CL 30 --Z:E7=R=.

o . S=JEry 1a=~, ~=~1~p, ~~tt ,ve~:7

LitLle

CO~~ 1= ve"~ z uQ"

SPTJ=.

~I !+!~ I I I 1 I i I ~ ;_~;1 f 2= Light

t t

0IR

!II

(c_

Srt.'tL :S OF K'-~-=

101

CC ~~ C'~\ 1-1 C~ i~ ~ l~ 1 b~ ;?~~ I { ; t o 9

Vc,-,_: y G~.~=- ~~ ~! l~i ! 1 1~ 1 15 ;i ;~ I ► ( ~

C= 7--Z ; ; -Y

P==v

I, ~

,

; l i I

B

rV

c^,•- - 1 (( /

'

~ L SyG~C uS & G'SC~:,:iGr~ 11

las `ed se~ er~ hcL s ~ ~- t tt

w ould the T

A

cause_

4

vcu to 1I' t t ~

A . Decrease optior~l or recreational activit-,7 List

B . Take addit~onG_ ~~dication

C . Be unable to pr`= or.-z the =ctmt of work that you could nor:q---11,7 perform

D . T= this workload level aow~ (aisrevsrd fati Cr le)

E . Be unable to FE::-forn your usual wcrl& activity or level of productivity

(` oc=ation, sc'-.colworkl , cr-iticsl household c~, ties)

F . St2y at: home s=--k' (lose sic'-, t; -.e from work)

G . v=

H . S-- rccm
p. 53

$'L~T=C:~r SCORE L.

G OuP

13-J16

S'L1BJECi M

Borg

DA=' i

COND . SC .`le

SCORDIG N,~ 2 cn tn cn >c r r ¢

h-i cV F- c'7 L-: I ~J ✓ 7 rL=

1=1ZNE 2J='~JDEZ?_'' U Q , tI , ~

~• C~ cn cF! -. C Cl) Cl C 1 i C H i'_ ) c.~+ 5=LR^-_Ci 30=S -E71B~'-%F R c-: c=: c c:2.1

a P-1 P- Cn

0 .5=Ve'`"%

Lit7- '

COUGH _ ~ { s r I+ 1 i 1 ~ i~~~ 1 ; 1= Very M, - ,~ I1`~I+ I~~~I~1~~ II2=~__t

~u~ST rT•'"? St7~.~._ ,`S

1 _L1 cr

OR _^- S I + ` 1

( ~ , r = ~ c_--==

SCrL :1HFn A

r

(Cr

rri1~. OF ERE-

! ~. 1 01 10 I 1 1 O 1)0 /0

DT SC~~'-R

CC-IN=-=N' i ► ~ l , ~ ! ~ , , ,~ ~ I ~ ~ __ _

~ = - ~ 1b~t I1D IC~~Z6

~--- , -- - - -- - , ,

Ir It I l ,

sy=- c=L,,s c~ discomfort

L :QLTrs

,

ould they ca-use you to

. Decrease optional or recreational activity List

Take additional medication

Be tn =-h le to preform the ua~an~n =ntmt of work that you could nor--rally pe -~orn

'r~ this workload level aac~-n (aisreQard fat---1'Z7-,e)

Be =o1e to per-=c= your usual work activity or level of productivity

ec~.~atien, schoolwork, cr~t_cal household dut~es)

S Lav at hc= (lose sic'-{ t:f1-~ from u,Cr'_:)

V_._~ room
p. 54 1~

MOLP

SUBJECT DID . , I

DAM Borv~

corD .

I

E~~e_ CP_

.~ C14 ~ Sc`le

SCORLTG

° ,✓ ~ cn <

1=NONE 20-`~D'.^-"~

P- cir E- L;r--; ►~ `n ~

~ ~ F ~~ O=\7CLtiin~

N ~ ~ ~ ' F E" Zi't ~

5'?~?~.E JO=SE~✓~L . r' X: "= ~ cn C I I L: V7 U] - c= c11~

U] c

1

_ I 1 [.D= I i ~~ 0

. J /e'_y'V e-=7 er_/

t

1-- Very 1_~' tc

c

l+~C_'~,-1-AL sop-r rSS L~Jl

2_ Lt

OR

I11 ~

ATv~iCr11h... S, I ~ I 1 1

to

.

:

r

OF B= I I~ ~ i- ~ VL~

.=__ I I I, / ~`

~!~-~ c=

i~U il o j/ j j

c=-E

ti=---

7

c= VE::--

REStc _c

~

\~ ~ I I ~ 1 i

; ,++ ~ ~ I

Sc_ --~~ I D 11 ~~

L: s=Lcams c~ d=sc 11 or~ I, I

I~s ted s evCrG1 I,I I

wz~uld they cams e cu to ~

`

A. Dec.re:.s2 opt_er.. _l or recreational activity List B . Ta ce additiona_ medication

C . Be unable to preform the ma.-cn m unt of work that you could nor_-Ti,lly perform D . T~mm this workload level acw-n(aisreQard fatimse) . E . Be tm.aDle to perform your usual work activity or level of procuctivlt-7

cc=at---.cr., SC_ C01~v~r1, Cr~t~C31 ~loLLZ^.old duties)

= s i?v at C1Cre S~C_~ (lose sic'-, time f--cm G cr:,~) G . v=si.t Vcur Di. -- ?r

~ -

v

~S L'. ~,-

"'."
p. 55

/L• ~'~ !l,~_ ~~,~. ~ Jt-_-__._ J ~ ~~ C~ "~ ~~ S✓ ~ ~~-

cRot P'

UBC r s ~

Borg

DATE E:mrt10L1

coNID . ~J N C11 Scale~

SCORING

p-+ rC/I c1] Cr)4 cN ,--+ m W~ ~J ~7 T i~i no

1=~I~1E 20 ~3JDERATE 9 . 0=0t

~ E-+ E-+ Z, i E- E cn E- ca

Cn M c, , r=. (n m at all

z .~_~i ~ ► ~ c~ c~ ~ w o c c~ 5=MA-CE 30=Sr"VE"c~, z c:: z w P-1 w cn

10=~7 40=INCAP . 0 . 5=Very , Very

Litt1~

Cnurld 11= Very light SPUTUM

2= Licht

SZJ~BST~~?• .,A7 SO :S

:)R A?vA_TE~IFFSS 3= `tderate

SORi Zr~L2T y; 4 to 5

Heavy

7HORr`SSOF ~ BRF~T'H

! ~J 'i~~ ~~ ~~ '~~ 1 ; ~ ~✓ i ~

U=

D, CljI

aF~/

~ ,.` 1 I .

f % to9

er•J He~~

~ l~~ I %I _0= Very, 1e ;

_~~ , •~

.rST TTC:~i.ES S/

; ,.~i,~ ,~J~ I

~-

-~_~.-~_

S?`=i~'S

7_ .~71)

, L! + } t

7i (0-10)~T ,

s=tcros & discomfor

=-sted several ho=s t - ,

-,Duld they cause you to

-o r _ , !1!

Decrease optional or recreational activitv Lis t

Ta_ke additional medication

Be unable to preform the ma.l amount of work that you could normally perfor':

11= this workload level down (a'isregard fatigue)

Be unable to perform your usual work activity or level of productivzty,

( occ.mation, schcolwork, critical household duties)

Stay at home sick (lose sick time from worIc)

Visit your physician ~

Vls~t an e er~e~cv rom
p. 56

SUE

_ 1(

.:r.(7. M, .

I D°== Bcr,1-

~ C7 i CL~ Z 2

Exc= _-4 cn

Cam . z t t

C y r ^ CV CTl F--~ I( L=~ r~'-T r ~C~! o

SI.O i 7',\ IV h- &-4

1=\ \i ~iP, (~ }-~ r- 4 F- CV F c'7

E- + E

~' z, t ~-« E..:

c n ' ' c n p t t 1 M U - 1 r--; ac a l!

=T~ACi 30=5 . r~~

. -r ~~ a ~ a c~

SIO==D /~= r p 0. 5="ie ._-~-~y ,

` L:Ltt12

cO

~

L~~

~

_

I( ( 4 I~ '~' I~ I~ 1= Ver i y Rt ; Q .

. I~i 1 I I ► 1 ~ ,

S~r~,~~~ 1 i I~;

I t I ~ I 1 2= ~.

S,-75S=

. ~S __r_

_

O ~

S =r? =f-A7

~ Z'

! I I t I i ` r;_

S~ ~OZV"~~ 7

.5 OF B~==^

k C); 12O 6_ =_ -

C-_'\~:~-~.1

C=°

' _

_ i I~~ I~ I ~o ~0 2~ f vl2of~~ -

^

-~=: '' C': ! ON

7-l--

'`-

40 -- iJITzojzo?n

C I I

`~ - ~ . oI: ZO

C=_. c.~,~ ~•~~ ~ ! ~ ~ tttt

`'V=) • ~ ~ 1 ~ I ~ ~ t~t ; ' l

K:r ='=-c~_Oti

( I I I ( I S ~I I~i

j

LT sy~tcros &~sc ~nforr t t I

1as ted severalhctiss, t t ,

would they c aus e you to 1 ~ httt (

r --'

A. Decrease optional or recreational activity List

B . Take additional medication

C . Be unable to praror;n the u ---t-iTrnlrn - nomt of work that you could nnrnally Pe D . 'I _~--form L=--i this workload level n aisre~ard fatigue)

E . Be tmao~ to per-=or,n your usual work activity or level of productivity

oc-,- .mation, schcolwtirk, critic-q! household duties)

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

C . Visit Your Physician

i? . Vs_- an rccm
p. 57

:~

( S-~-S..,~c-, ~u -_1~°l~

DA=-

M C7l t t C^ 2

WL

` 7,-

~ LLJ . '

~✓ r+ N c''1 'Fz-- I{ 1 L=: r- ^ ~C~~e

C!1 U] Cr k 1 I <

p- ( F- r F~ N I- c"1 [~I C Q:YO 2'J=' JDER=

5 F"_r-- X' 16- L- : :< G G1

at:

, 0

p L': G~ G f ~ ( t^ . . R.. 0fx+ U3

.5=~ie _T-~,V 40_-.-DKAF .

CDT-=--,

_ 1 01 'D ,D I~l jol I0 I/~

Sc.~~S ^_:•`? ~C~cc=~~ ~

1 I 2= Li gil~

LT

^

ec~ L- - ~ ,sl

(c= 7 ~-~ C= A

rin

c=,~y~~o~ 1 a- zj~~~~

'..~~.~_ . _-

_

'_ .V

f

~=

_,

~ ~in~^ ~ ` ► 1~~ ~r, /~~ ZL~I 7/ t , `~?l 1 t ~ 1

r7---Z

2 c

I "

~

T1

X-(- 2 L 7 l l

r- ---• - - -

.`° /

( ~ t ( i l ,

S C-1,_ ._. (G _ _) (,~2

= s-=L"T,S

46

1~ J ~i t „ .,7culd they cause you to

. , . ,

De^.. .r~ se ert--or-,:-: I or rec;eati.or.G .l activity List

. . Take aecit=cr,a]- T- edica.tien

: . Be t-:b 1e to pre=orm the a.,rcinzt of work t:~.=- you could nor~l7 perform

~ . 2llr.i this workload le-.rel ac~~Zi (a.:Lsre~erd fat=,;se)

Be lma.Die to pe,.=orn your us'u.?! work act -V---t-7 or of DreCLC~?~T ~j

(* or::-=ac-. on, household

S av at home sick (lose sic?c time r-rm r'_1)

%_ s

7 your : .r:,rs - c-
p. 58

c~-~CUP_

~ ~~Z t~l • ~~ t t r

S-UZ'`~JEL 1~,t~

DP

,, / ~ c^ c: ~. z

C: ND . C 4 r N M

Ea~rL .J 1~~C F"' ~~-' C ~='• F-~ t t- i F~ F= =

Cfl CJ7 ~ C!] :G 1 6 ~_~

!L~

.~ r "Z t- r f- N 1 Cl)

l=:• '

Z ~= :t U ~•

=_,!:DEF?_E U: E- U. c1 c:

1

1 E ~ 0\c tHLZ

cr. c--• C/I ^ c~r c tr.+ cn

X

~•

1C=: J= ~ =v=~~ '. ~

I0 5__~

~

1 1 .~- E_'-y

,

T -i

ZOLC-l _ f s- , a 12o 2~I r(J , , ~ i~!~o ve_ T 1 ' _~ ; 5 11,

~ I111 12= Lishc

~~'FE u~„~ ~

;2. :

1=

J I

-_ l (`.

I - _v

:

_ ~

1 ~ !

i- ~-- ~_...=_1~ ~'_i ~ ~ ~ t t ~ ~ •

.y It .:~ •_-t_ _~ ~ ~o i } ~ ~ ~ j ~ ) t ~ ! ~~. ~~ ~; ° °- ~

. VC..r, , VC-

-:Z

=:Z77 7-1T-.^. 1 y t t

t

~t

- - -.- ;, ;

--

. ~-'~ N7E

'V' W~ ` ~ ' ~• `~ ~ ~ 1 i I

III

i

10, n

`- (o-i n) U\

~ O22H ! t

as tad S2~T'crc! hcu-rs

aul.d they = -use you to

. , . -

Decrease ootiorj:--"i or recr°. eticrall ac-:--*-I-i[:-7 List

Take additional medication

. Be able to preTorai the ma=~= of work that you could r.cr~ly per=or_r.

Ti-=- this w-arl-,ieaci le:el c~ ~i (cL sre ~d T

. Be able to pe=--o LL ycux usual w~r'_c ec ~~~r --77 or level of prccu tiv,i -fJ

(* OCc'r.T^.ct=.CP. , SGLCZ~vZ)r'Cr critical household du-tiles)

sLa-v at t1CI:'.L. sic_{ (ICSe S ick t'TT'P r--= C-,c r_C)

V;-s- ycL. p~~7s-c= n

V-, -- ' an rv=
p. 59

I~ I

.j&Mc: r

I!II!' DP'

Borg

Exertion

COND . ScN M :1e

SCVLLtTIZ '~'; Z (!] G] CJ7

c'~ 1 o

L

H H LI1Q

vn cn Er cn I I G~ =I 1 ! F H ~

Cr cn at a

j

_

5= ~~ ^_CZ- 3G=S71-W=-%F x: W g ! c oa-1

G -N+ `~"' • J P

+ F

P0 . 5°77e1"y, ve_ 7

1Q=`~.~ '-W=ENC-Ap . 1 Little

MuGH 57J5J5OO 1, /01 5 1 1 - ver_31; a, ,! I : z7,jT T--~ Is Is I 1 ~ f~ , ;~ ~ 1 1{ 1{ 2= L;ght

`~c -~?.-

,nj ~~=EZ-5 t III

--

to 5 _

*~o=-,v

c7

7

5' _

Ve_; _

:--:~ 11t~ 1 J~~ ve ~-; ve=,

~ _-~~~-`=~y ! ; ► - r=7; :

_--~ , r- _ j , f ~ • i ! ~

I

-- - -.- ,

f~1 1 ILLH,~ = 5 ~-, Il =LC"S d~sc.,^IIli.or~ I

!0to

Dec=ease optional or recreational activity Lis t

Take additional medication

Be =able to preform the arrnmt of work that you could normally perform

this w-orikload level down a( isregard fatigue)

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

(* occucation, schcolwork, critical household duties)

S~-av at-- home sick (lose sick time from u,-ork)

visi~-- ycur Fhysic~:

. V= i -- an erergercy rcc.n
p. 60

u~" l .`_ ~l w`vf =_ I

✓ / 5~3

M

SUBJECT

.JUr l~

1\10 .

111 F ~r?

D= p~1 Exer_tion

~

COND . N M Scale

SCOR_ ,TG y~ ~ w' 2( cwn ~

~ ,-a C14 0=~Io t?-:n 1=~rM 20~JJDFRATE H H a F z

cn cn

; E, H g C n cn at all

5=TRACE 30=SF.VFnE vI

10== 40=INCAP . 0.5=Very,Very

Little

COUM II ZD1201 ~127 D1 -ZU12012 d, 1 fC~ 1= Very light

sRMJ-M

12= Lig~nt 15- SUBS=E I'?QL SCR=S

DR ?SvAI IESS

S C R V T rTD A _ T L to 5=

(or MA.-_R=t~SS> 1 ~ ~ } I 1 , ) , / H ;

~y

.roR~ ~ S OF BRF?'M

1/0 j~ ~ 1 J~ k

~

5 1 6= haavy

:~Aa%. DI SC<:AJRGE/

.~ti~s=!oN 7 to9

~ ~ I ~ 1 , I V e r-l

_

HG. ..avy

~ I ~~~ I 1~~~ 1 f ~~~l 1O = Ver-7 , VerJ

-_"

...CT Trl=-1_S/ ,

==T?I=N

'r % 0

.177 (7 ,

~ti2Li_'~- : NO I

~

c-K- _-~ -IN

/Z- (0-10)

if symptoms & di scomtort

as ted several hours, ~~'~

,ould they cause you to

4~" . - . -

Decrease optional or recreational activity Lis t

Take additional medica.tion

Be unable to preform the maxLi an amount of work that you could normally perf=orm

) . Turn this workload level wn isre-ard fatigue)

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

( * occ,.mation, schoolwork, critical house-hold duties)

Stay at home sick ( lose sick time from work)

Visiy your physician

Visit an E-n-ergeTcy room
p.61

C~Ou'P ~ I✓ v

(~ 1 1(l~~~- ~~

SUB.JECT iu . 0,Z

DATE Borg

COND . E Yertion

r-I N M Scale

SCORING H~~~

1=71',MIE 20=_\,DDE~,?TE

P.

.-i F- r{ H N H M c-x-! 0=\TOthing

5='I~?C'S 30=5 ,v ~ -~ --~-- ~ [:~ ~cn c,r,~ at all-

. X 1-~

a a~

10--=_~ 40=~CA~' . 1 0 . 5=Very, Ve~-T

Little

c o uU - 1 1 / 0 1z

S~~~ I I Very 11 1= Q;_gnt

S'c3SEAL 2= Lig~jt SOF~~r.rS

OR pSv?~IES S 3= I1bderate

SCRE =R~_= 4 (or F.C:-`_ .S~IF.SS) to, 5 =

, 1 I 1 i 1~ 1 ~ ~ ; ~ 1 1 j Sc-LL! E w:at

S:oR_IESs or BREA~~ Heavy

1 3 0! _ 16=

~ Heavy ~~ T D 1:

1 ; ~oa =

~_-N Ve=1 'r'.ea ,- i

-~ Ve~--~

_~~T

::=S7 I lo= Ver

Tc T-r

r~

_ ,1_ T0 NEe:w

_Z%

-- -

4,-

1L^_C CC'` " i NIS

1 7Q7)

Sl;i.

G 7\:~7

C-A T~-~~ ~ - . 10)

s~VIIiDL"Irs & disc~Ltor t

_a.s t ed several hcurs,

-ou1d they cause you

r

to `

~'.~ Y }-r

. -u • . ~ _

(

Decrease optional or recre~--_ tional activity List

3 . Take additi.onal medication

1 . Be Lmaole to preform the ma ..-d=un amtmt of work that you could normally perform

D . Turn this wor'k-l oad level acwn isre~ard fatigue)

~ . Be =b1e to perform your usual work- activity or level of productivity

(''' oce..roat;or., schoolwork, critical household duties)

S iay at home s ick (lose sick time from G~rk)

Vi sic ycur pn, ., s ic -n

Vis_ ~_- a;. E~~r_°^c 7 rcc~
p.62

GROUP

sJS.1ECT m

, „ sas

d

DATE Lcer O tloII

COM .

r-4 Scale `

n

SCORING

~, ~; ( H ~+ ~, ►- CrI ~- O=Vot' 1=11UNE 20=%.DDERATE H H r_~ H Z~ H H

U cn, ,m cn cn cn at all'

- 30=5 r V~~. r= c ~ c 0 5=TRACE c

a c:.; a w a P . Pcn ile _ 10=`~D 40=~ i= TCAP .

0 .

5I rY,Ve'~y

LittLe

CO=

1= Very light

S

PUMI ~{ I '' 2= Lig~it

SZJBS=ITAT SQR=-j

DR AZTA_IESS 3=Ybderate

30

(or HOA

Fi 4 to 5 =

-R..'SS)

lit Heavy

7HOR1_ SS OF BRa= + 6= ve.:z,y

1A SAL DISCHARGE

:~~-~ST_0 N ' ~ to Q ° t 1 .

Very reavy

vr=12

IG 110=Very, Very

:HEST TI~~~SS~ Heavy

?.EST'tZICTION

, ai'IC'-il~

=E=ON

7 =ST)

;oRC E-R=oi1

;C~J~r (0- 1 0

syamtcss) if & discomfort

as ted several hoi---s,

=seyout y o

Decrease optional or recreational activity List

Take additional medication

Be mable to preform the ma-mm a noumt of work that you could normally perform

) . M= this workload level w"n (disrecrard fatiQue)

Be unable to per}orm your-usual work activity or level of productivity

occ•.mation, schoolwork, critical household duties )

Stay at hcme sic~ (lose sick ti- from work)

Visit your physlcim

room
- - - -- ---- i , p. 63

-} L

=cCL~ • ,~1~ , t`

u~LTrCi ci

3

E ~ 4;tt h_,~~~ t t ~cr, ~~^r (Q 7

~

'~ 2 ~~° ~Grl 1111:2

ND . ch ~ i G-L ►= 7+ ~Cc? e

:,--OR G ~,^~_.' 2 CIl C!; CI] rt 1 ~ ^'_' ~1~

T ~•'~ ~ r- N ~ ~

: U ~~° V-`;Ci~i'' 1C 20=v1DE~A=1 cr! 4U

L

C ~

z : 1 F- E-

-l~ ~ ~-~^ 3 n ^ r• r X: F- 'yG L X C= i< [= C t C C C= ^~

._

O . ~='~e-.'^~, V Cr~

.

.

_T~~t ttt

3

LC~ `' I I .r1 ,

= Vez.-r

1 2= Lic;_ ~~~=_ ~_Ty_c.~'

E: -~=. r

,tt t~

c= 20 20 12 L 1):

J,-~.

,,

IzDl~1S1~;I~1 CS I )

~_~,~ ~ t t t

~ 2D ~, .~~

,

_ _ _ , ttt

==>L _ C~,0 l

(o~ L,,) ~ ~ ~ ~ 1 ~ I ~ l~ ► ~ t,t

s ~~tc-LLs &

- ZeQ ScVe'_"S.! hCLi5

-id they caul e you to ttt

. , . -

~ec=ease o-Dtion-:,-l or recreational act_vit-T Lis t

T.--'--,,e additional ~e^ic:.t_cn

Ee able to prerorm the mG~.~m ~um t of work t:-.at you could norr-o-l ly pe_,=cr-!

~i this wcr~_ead level . ecc-z aisrev~d fat:-; ~,e)

e unable to perform your usual wcr'-"' activity or level of preducti-vi t-7

~-.

( occ:~a~on, sc:.col:or_c, c ~t_ca1 household dut~ es) •

:7~--av at hc^..:_.P sick (lose sic?t t P f=~ u ~r'_c)

~i_ an =-. °,-,~rc' r~C l
`. . -- ~-- --m p.64

Iv --~

G~-z' C• L

tt

SUBJECT M, . ~' c~,~

DATE Boro

E~~ertion COto .

e--I N E-I C1 I Scale

SCOR?,TG ° r o2 cn cn ; c~ w c~ [

cn ~-

F-+

. .-

~+ ~1 H r t-+ N H ~xtd

C E-, G*

7 1=\UL1E 20=`3]DEZ4-

-17

H

0='Nothing

5=?~ACD 30=SFV~~, o o a ~ M o t r:1 ~ cEn p at all `

~ ~~ a atn

10 ~D 40=~ CAp . ~ t 0. 5 =Very, Very

Little - COt;Q-1

Spti~M I I' 1- Ve

-

y light

SLBS T~~I AL SOR=-S ~ ✓ j_~ 2= Li;nt

OR AT,

^_ I ! + 5 1 v ~

;?=TFS S

5 1 T ~ 3= Moderate

Siv,=. Tl- 0

A= r t ~

(or =

/

f/- .

~

4 to ', 5

✓

H

}

LLI

S~_~NiZGt

S'_ORrT~SS OF BR-A.--'H- ~'°~-=vy

16=

I I I

6= eaT~~I N?- S -`? D C

Cc~:~~

7 to 9 I J `~ tlt Very Heavy «r~ . ~c

~- ( 1 I ~ ~ I ( I/ orb 10= Very ,

-' l.~i'~.C. C l ~

~

l._+Z

Ver-% .Qi

.:%

Heavy

i ~ ~' ) t t

~ , tt ( io / I

l ;li ► jr ~i/~;~~I~l~l 3`iiHER S<r 'NS I ~ ~ ,~j t t

(T_=S

7)

3CBG 0-q

SCALE (0-10)

t I _f sy=tcros & cli.sc..,~

^

ort

Ias ted several hol---s,

:vould they cause ycu to

ttt~.~

tlt _

Decrease optional or recreational activity Lis t

3 . Take additional z--Pacii cation

C . Be unable to preform the ma--dr= aa-oumt of work that you could normally perform D. Turn this work-1 oad level -n aisregard fatigue)

S . Be tzable to per=-orm your usual work activity or level of productivity

occimation, sc:.oolwork, critical household duties )

. Stay at home sick (lose sick tirn,- from work)

= . Visit your physician

~. Visit an - =-e-c,,, rccm
p 65

SMIT-lax SCORE SHEET

GROUP )DY-1

SUBJECT NO .

DATE Exerti

Borg

COND . r-+ N `'' Scale

SCORING

CD

1= 0--Nothinngg~NE 20=~9DERATE 0.

~i H *-' H N H M

U En

U.

cHn

U.

~ ~o ; ; c~n v~

Q

i at all

5=TRACE 30=SEVERE

I

a °w °w

0 .5 Very,Very

COUC

10~`~D 40=INCAP

H

. Little

1= Very light

SPUTUM ~( i! ` I I;~ ;~ ~ 2= Light

SUBSTERlqAL SORENES S

OR AIdAI=S 3= Nbderate

SORE THROAT 4 to

'

5 =

(or HOARSENESS) Soai--.,;hat

Heavy

SHORT=SS OF BREATH

; ( I I~ ~~ I I( ~'' ~~ 6= veavy

NA.SAJ~ DISCHARGE/

CONGESTION 7 to 9 =

I I \ Very Heavy

M-=ING j I

I ( I , I( ~ ~{ I + I I 10= Very, Ver:

=T TIGHTNESS/ g17 Heavy

RESit~ZICTIO N

FATIGU'E

I 1 ~ I I~ I ~ I { I' \ ~

HFe.DACHE

FRD~TAL : M YES

IRRITATION

0=SYMPZl7NS

(LIST)

10 -- -- -`, f t-~~ f

BORG =TION

SCALE (0-10)

If symptoms & discomfort

lasted several hours,

would they cause you to 1 l ~

A . Decrease optional or recreational activity Lis t

B . Take additional medication

C . Be unable to preform the ma--ii . nmm a mtmt of work that you could normally perform

D . Turn this workload level down disregard fatigue)

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

( occupation, schoolwork, critical household duties )

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

G . sit your physician

H . Visit an ~: :er-ency room
. 66.

---

~uP

73uB.rECT rU .

,ATE Bo a

E=m--taon

MND .

~r ri N <*'7 t••{ i[;I ~! Sc.a? e`,53~

3COR7,4

V] M

. " E~'''+ r= 6 =

0. r; +--4 c" c*~ L=MrE 20=~D~ ~~ U a=vat_~T

E- E- g E-i '

5='~ACF ~ "

_

'-' = c o -1at all

a cn Lo==D z.o== . o . 5=Very, Very

MUM ~ ~t ` I~I ~ I I I ~ I I 11=very liQ ~ iZjBSZ 1•.T4T SGpZTzS M2- I~L~~lt

~

~ l to 3 - I~derate I{.~ to ~ ~~.L ~r~~l.r'C" ~

i 1 I '•

or M L R.,5) it i F4 to

;5 =

i3 H e=-1y )Rr~'~IF.SS OF BREA= H

Ac

o= He:~y Al, D, ca_pR=-.- /

% to °_,

- Ve-r-y, Ve-~°'j T T1C_I~SS/ -l ~ ~ ( ~ 0-

7SON i 1 I I' ~ f to vy

~ ~ CU

[ ( Ji

_u TCr ~ j ] ~ i t i

=,R=1 ~7

'CSV

717a.. !

_

)

Q

~ Ie ION

I I

-ALEE (0-lo) I I I~jl + ~ ~ ~, i

- syrrotcns & disccmforZ:

=_sted several hours , ~7

D uld they cause you to

Decrease optional or recreational activity List

Take additional medication

Be unable to preform the m^ xim+ m -motmt of work that you could normally perform 'IL= this workload level dawn 'aisreQard fatigue)

Be able to perform your usual work activity or level of productivity (* cc"mati en, schcolw-or'_{, critical household duties)

S ~ay at home sick (lose sick tirrL- from

Visis your physician

Visit an E--le rgency room
p. 67

71

=Tip 0

V\t TL

a>

T&TE

EE

:,T MI

n-/7`~6 Ifl ,

. POO

Irl ~

ril Bcr-_

=cnCOND .

r+ c4 c*i t-i 1 ~ ►_ },

.,

.C.l.

-17\11rC F+ ~r? C- ~- 1I

C.' ,Z V] C17 r7-: 1 f~ Q L

1

I N C*]

\GD.rr ic t

C L LI ~- L

:

: __

5=1MACE 30=Jt.V-F" C C^ c~ ~' `

~Q-~ ~ ~=i iNl.c'~'. ( 0 5 -

7Ez

J

17 r

_Ill(I TIf '

COME

- vL~~ -

'~! 2=

~r._ n L

1.R

F5I ^

=L_= ~_~.. C

r _~

i

77_ --- 1vr

' 1 ; , , III ( ;' ; J ~

V

---

:~.~=~!-~V.~ i( l , i I ✓

i ~~i~~ i i i f ~~ ~ !

_

C ~-

& di.:

1~~ I l~s t~ s eTrerel h:, ~ s, ~ ~ 1 1~'\

would t!!ey c: us e ycu to

- ~ .

A. Decr`sz opc:Lcr,;n 1 or recreational activity List

B . Take additional medication

C . Be ts:~1e to preror~n the ma .- -n = mt of work that you could nor_-~1~y perform

D . nsZ this wcr_Lc.:d level c.cw (dtsre~srd fat_m ~e)

L . Be t1~Lole to pe_or.n your usual wz~r'.c activit-J or level of productivity

( ec:z---at:=cr_, s cHccl:,5r'_c, c~ t;c? ficuserold duties)

= . S tlay at home sick (lcse sick tzme from u ;cr:c)

G . Visi_ yc= p;.:; IcLan

V_slt an rc=
I p. 68

GROUT60 {~{ SUBJECT M .

DAM Bor;

E:mr=,' or CGNID

Scale SL~'G r= r c

14

c~--n Cn Cn xt tt a'- ? ~ ~ , -; ~ Cn

r. y, - C I ~- C L E_ { { O=tiCCt1?n~

(1 X E_ 1 Cri .. . G-_11-

~ V ~ at

P3

F•+ '-1 CI]

0 . 5

COUC-z _i lll~ ~' ;,, ~ I

- r {, {

.,cE

L'rL~ I

I I - ve_y I_~zt

I2= Lig!,-

C, ,_ ~L•~.~._~~~.,~ .T--

~,`''

-

~ _. _

. I I { 1 1 1 I

- ~ 1 v/t I ~ ~ I I~ I I 1( -~'L'C= ---

/ ~~ I {

L

: z

-- -. ~..r•.~~_. . . ~,r ~ T_ = i ~ ~ ~ ~- ~ ~ ~ j / .~ I , i , { - _.._ ,y

f

a;~~ T

_ _- • ~ I I ~ _-- _

1 1!/~, ~ T~7

C-~

---

:~.~_t

- `~ 2-~lDl ~•~,( i~ ~ =.`_ w _

l= ! 1 ~ ~ tt, i~ ;

i i i •

-- .

. ~~' " ' I✓ ~f I 1 V i I i i~~ I

l~ S;~t~r_S c`c scrZaStad s2Verai ' .CL.s ,

would they cause ycu to ~ ~ 1 {tt, ' ~ ~ •. ~

~ t • ~ . { ~ { --~ I

A . De==z: se optic-pal or recre

ation al activity List

B . Take additicna? T- d;cat-fon

C . Be Ls=le to pre=or:~ the =c-,-a-m =c,-,.,zit or work that you coLLIL d nornp-l lv per=-o=

D . iIMM t`Zis wcrclcad level ccwti sre~.=rd fatigue)

L . Be tm~Dle to pe..--~orsi Y= usual work activity or leve_ of preci ctivity

cc-,r=at_cn, sc~.cclwcr:c, hcus el~iold dut_es)

F . S t::-v at home sic_: (lose s;c'_c tfrre f_-otn work)

C . Visl- vct r

H . V sit a- ~ ~r ; rcc~

~~:
P. 69

~/ n~'✓~~ '~ SYMPMM SCORE SET

GROUP

sus.TECr NO . l ~t

DATE Borg

Exertion

COND .

o , r-+ N M Scale

SCORING

1=11UNE 20=~JDERATE p;

Cl)

; l, 0 Nothing

5=TRACE 30=Sr VEIZE aM o at all

Cr.

10=~ LD 40=INCAP . 0 . 5 Very, Very

Little

COUC H _ _ ✓ I 5-,

;- 1 '~ 1D I (I;- t i 1=Very light SPUTLIM p /"-

2= Light SUBSTEPI1AL SORENES S

OR AI qAR',SS 3= N . 2

bderate

SORE 'IIHRiJAT 4to ,5- (or HOA.RSIINESS ) Somewhat

Heavy

SHORTMSS OF BREATH h 6='Heavy

NASAL DIS .ARCE

.5''ION / C01~~ 7 to 9 =

() !. 1 Very Heavy

W=ING

=

10= Very, Very

RESTRICTIO

T TIGifiLNESS/

N

✓~ ' ~ Heavy

FATI

r

0

T ~

YES ~~~

~

~~)

oTI41-r--D. S =NS

(LIST)

BORG E.'ZTION

SCALE (0-10)

If sy=toms & discomfort

lasted several hours, ~ ` n ;+-~ ~ ► ~ ~ ~~

would they cause you to

A . Decrease optional or recreational activity List

B . Take additional medicatio n

C . Be unable to preform the max=rum amunt of work that you could normally perform

D . Turn this workload level ~disregard fatigue)

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

(^ occupation, schoolwork, critical household duties)

F . Stav at hc:-- .e sick ( lose sick time from work)

G . Visit your -hysiciar.

H . Visit an (L-":ercY ency rcom
p. 70

S,~_T _Ci•_ ~..:r.._. „__._

C~`UP

, Fo BJE„r"i r;a .

?crDP " F--Cc=

CrJ1V-?i . z~~i ? S z

N t`"1 C=•a.-

~1~

C ~ (/] C4 CI] G 7 1 Q

F= N F- Ct S f Ci ti ~ TC Ct~~

c-, c~ y c' 1 r 1 c~ C _

F C C c L t E' E C r l1

CI] c._. f!; L': CJ; C W. Cf] C!l =- a - a

5=MACE 3G=r_.'7Eti y >c r ~c G_ X ~~' >c C='. C C=,

U7

~ Q=~ ~_, T(~' p

10

. .~=VE'~'J ~ Ve_'~'f

j. ., 1

C^ut~z _ I ~ 6J61 i= v

~~' =~~` I {~ 1 { f I ! ~ 1 1 2_ L~c-:,

5,--~- -r~ -.~., ~ r ~~{~ f'i : , L• -- :, _

i

/ I

I {

~ ( t t , ~/

~- -__--

C:

:~-----`

~~ ~~i,. ✓ , , , , t ~' ~ _ ~~. -

I ~~~ / (` ~~ •~ -'-; , ?i c`

___ _ ~i I I 1 .

' ~~ ~ 1 ~ i✓ I ~ ! ~ . ~ I\ 1 I ~ (

C ( t 1

L S t,--".s ~ d_sc=or4

wauid the

las

ted S2Ve?',1 hcL--S, 2 t t. ~

y ca-use you to

A. Dec:

;-.se ont-_onal- or re_r°~t~or~1 acr-±:vic-,7 List

B . lakee additional medication

C . Be unable to preform the >TL-: ~ -T=t of work t:- .at you ctuld m=1117 per=o=

D . 'I~---i t_'zis workload Level ccw;i(aisiegard f~:.t=~~e)

E . Be i~+-aDi .e to Fe_,=or_n vcLS us-,-7al. work act:*..vit'T or Ie-Ie1 of productivity

(r-- cc==at-on, sc^col:~ar'_;, cr,~ t=c household duties)

F . Sw at hc'.:'.e s--'c:: (lose sick from

H

G

.

. Va

V~ an e^~

- .s vcur c

er

cn

^e-c

rs ic=

.,

.=n ~

~

rcc.n ~~

.
p.71

S L-ITTC~1 SCORE -Zf=- T

G'2i f)UP

SUB.3ECT M . /(0-

0 DATE

Borg

Z Exertion

mm . ~ r--1 N M c-+ Scale

H

~ t~

~+~D~7

SWL~IIYG F--1 C!) C!1 Cf] 1

<

♦ C/1 U ' O=Vot_h~ng r--4l= E 20 ~DERAT . ~' U U M

U3 Z U) o

I I

~ o

c~n cHn at all

5=TRACE 30=5FEV E, , F o

. w

t

10 `^~.,D 40=LNCAP .

. 5=1ery, Ver

Little

•~ , ~

COUG

H Sn-m ~ S~'3ST"~?T• LaT SORE-,T-SS

2= Liaht

l ~

DR. cQT.1

ltl J .?= 1~1Jde_"a te

l.1Ri TF~ERDAi'__ ~ ( I+ + I 4 to '5 _

'C-Lr a

~~

JCD L.' -S

) 1 I ~- 7 ~ ~. , I 1~ ~ I`•

.C•.C,.T~~vi__

^Ocv.`r'~LSS OF BBEL~~.=

--)N~ST=cN ! f~ ro~ 7 to 9

ve=-:

= .~T TTC-. raavJ

_2

•~ ~ f ;''~ i (

• ~

~.--. ,

. ,

_'a=-C=

-7-~- ti-L = : ~

-

S'r-u~ ~;~,",7S

i I

_~ E:=i-, _CIN

_ synmtoms & discomfort

=sted several hours,

~uld they cause you to

Decrease optional or recreational activity List

Take additional r,~e dication

Be unable to preform the ma.ds= =imt of work that you could normally

Turn. this workload level do dlsre~ard fatigue)

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

(* occ.mation, schoolwork, c---4t-:cal house:r.old duties )

Sr-ay at home sic!-, (lose sick time from work) F•

Visit your physician

Visit an EIle_"~~'__C~T roCTTl

~- ~

/
p. 72

~ovp~ ~( _ ► ~j ~

.73aJEcr rU Gv {

Borg

~ATE ~ C.' , -' Exertion ,--ti.on

M1VD . r-+ N cn ~~-+ ~ r Sca1e

.CORING ~ t M

~;

I

~-: c*~ O=~Tot

~ =~IONE 20-`~DD~RATE ' U.

; v cHn o ;~ vFi r~n ~ at3g

~=TRP.CE 30=SF~V~'~ ~ w 0 o r-~

_0='~2D 40=INCAP .

0 . 5=Very, very

Lfttl~e

'JUM

Very libnt

711J'1'C~2

t) PC) f 2= Light

BST~',~T•.iAf SOR~~S=

~

3= Moderate

1

~

=y Tr=RD? T to 5 =

-- '.OA-Q .S'"L~SS)

Heavy

JRr'SS OF BREaT'd i

16= Lzatiy

_'P7 D: 17 1 C:I ?RGF

_NGE S iION i) t 7 to ° _

✓ ~ ~ Ver-I Heavy

~Z LTG 2 .~ 4 1~1

y/1U IJ -~1 /~ 2~ I~I ~~ ~~ . ~ ✓

~ I I I I 1'J= Very y Very

:=:ST TIC-: -'T~SS/

~CTION

J

7N-rr,T 'NO 1=1 Z~ •,~ ! l~-~~/,( ~V~,', ~ ,~ ~4~ ~ I

-~~ 0N

_-R S7_MS"'MNS

E=T_oN

__'`~ P• ~ (0-10) _" ~, ~

syarotoms & discomfort

_ z:ed several hours ,

d they cause you to

Decrease optional or recreational activity List

Take additional medication

Be unable to preform the ma-dsrnun amount ',f wor'_~. that you could normally perform

Turn this w-or'~c.load level ti isre x ard atizue)

Be unable to perform your usual work acti tv or level of productivity

;J occupation, schoolwork, critical house_ old duties) ~LAJ~

Stay at hctr,e sick ( lose sick time from work)

:'isit yc= physic i=

isit an er.eroenc`,7 rocIa ~~1 `~~_ L 1•_ti • ~ J
p. 73

s 'TTcH'. SCORE S=- 6v2 ~

VlWTUr ~ I l

J V D. J- EC L M . , ~.

D,4=,

Borg

E

:mr

.

n n

-~oII

SC= e COND . r N c- sz i~~_ 1-7 1117

SCD=j,;G c z cn cn cn

Tr '( - H r F- N F- cn G I( C:

E- E- F- 1 1 v

0 Vot:`L~Q

cn cn Cr , cn cn = a

t

5=!R^-' 30--c ~lB=ti. C-- C C

I

.O-ur' 0.5="iery, Ver•7

t Li-

.7e--7,

COME - ` ( I~ h I '~~ / / 1= Ve_'",T liQnt

qpUru,

` 2= Li(:~,

~~==CL-SULti_~~=.J

OR AT.9- ~~=;

(//3=erate

A:

C~R~`~lL.~~.J OF R`Ci_=_=

_ Tc l

__ ~

J

I ~I~ ~ I

~~~-T D IS~`_^-_~ / ! I

17 to G ~ -

- ~ VE=-. _°.=v 7

wE--~

V=;,, Ve-- ~_ T

=7 . ~~~ -- c=~-C=--~•= ;/

-~~J 5',5 ~

~-_~~• • / / ~ / ~ I I I i I

` I I

~ ~.i'(' .~'•=•~.- '.:i~ I I I

If s-=tcss & disc..^=Ll orr

lasred several hot=s,

w7)u1d they cause you to

.~ ~ • ,

A. Decrease optional or recreational activity List

B . Take additional medication

C . Be tumble to preform the inp--dTrn m amount of work t_'- .at you could nor=-I ly per=o=

D . Turn this wor'_clcad level aowzi (ai-sre~ard fatigue)

B . Be unable to perform your usual work activity or level of producfivit,T

(J oc"mation, sc:~-icolw-o r'-, c, critical household dut;es)

F . S L7--v at hcme sic-`{ (lose sick, t; m- from work)

C . v ycLr ph17 s- ci.=n

H . V_ an E . n r ~c ~- y rccm
p. 74

GROUP

SUBACT M .

Borg DATE -~5 ZO ,

1311 Exertion

COND .

! r+ N M Scale

SCORING . ~ ~_ ~5

1=NONE 2o=`~JDFRaTE c H r-~ i-i N F-1 c

c

n a 0

O VothlSl =- g

K-,' C: E) ~ o~~ic= ~ c~n at all

5=TRACE 30=Sr V 5Z: F" , , c= w , o c ~i

a cn

10-D 40=I~i1CAP . 0 . 5 Very, Ve`-y

Little

COUC Ii

(

e

SPt)TUPT 2= Li

ght

S7j7BSTEF1,!aL SCR,;~"

DR AMA-17=13 S 3= N4cderatz

~ORE LrtiDP_T 4 to:5 = (or HOA_ r : S)

T ,

~tiORZ~jS OF BRLLT`=

~~~

6 veaVy

\14-SAL DISC<-?QTtC-~'._"- /

SONG-rST_ON 7 to ° _ I

Very Heavy

10_ = Very, Very

ZFS TRICTION

=ST TICr~_1ESS/ HeaW

' ► ' ~

17 ; l ~! 1i 1 ~~!!1 l !

:Ej_1ll " ~~-~~L :~ Y~ ~~ I I~~ C 1~ ► ~ ~ !

±±WTT1'

JT'r-~. .~ s L", : VNS

30K- E~T?"ON

s C'~J-7 (0-10)

If syrimtcros & discomfor

Vo several hours , t Lasted

uld they cause you to

;,-

k . Decrease optional or recreational activitT 7 Lis t

3 . Take additional medication

C . Be unable to preform the ma-nun amount of work that you could normally perform. D. 'I~jrn this work-load level o(disreQard fati gue)

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

oce,..mation, schoolwork , critical house~old duties)

7

. Stay at home sick (lose sick t~~ from work)

~ . Visit ycur phvsic ia.n

~ . Vi sr'- an =.er-encv ----cm

\. i,
p. 75

SK=T~.

G-~f

Su'B

;L-

.~ ~CT I~

't I

L1-°T^

COND

S

. BOr~

~7 G ~ ~cr?

.

ca cn Sc e

SL0=1 lC

~ ~_, rcn C!7 C!1 ' d ~

► = C14 cr1 , O=~TC L:17; T,. ° 1=~? J L~- ~D~c U1 E~' C U C~

C t

C5 F E" = " ✓ ` ~-' U: V'_ Vl c { C= cn t!] - ct- c

^ 5 ~-_~ D 0 r , ^' C C ^-~ .vz=. a l a cn

0 . 5=.7e=~r ~Ie 10=~ ~0=E~?. ` ,

CO~z TJ7L=V C

ct ''r

U

;---

--

cr=~~~~~_~) I „ I

~ C=

C=~

7

~~~__'._ ~ ~ •~ t t ~ _

.

~ =---

- ,,

c.~-_~'~ti~~ ;

,

,, .

~~_ . ~ ~ , t ~ ;~ I~ ~ ; i r 1, ► ~ ~~ ~ _`-(C_~;

~~ s; ~~''S Cc CiSC~ iSCi ~ I t t

ttt laS ed, s eV2r?~

i='to

A. De--re= e optional or recreational ac r, :-,Lv--CT Lis `

B . Talc--- additional u~^ ~ cur=cn

C . Be unanle to preform tie ~a:=-mm ~mt oz wor'_c tnat you could r ormallv peYorm

D . 'I=_ this workload level cncV~i (aisre~,d fat_g+ 1 e)

E . -Be ~bie to peper-_ -;-o= yc= us-~1 wz~r:c ec=4,vit-r or level of precx:etivf. .tl

cc::-=etacn, s~:ccl~~~r:, cr;+-c~1 household du~es)

F' C i? ~T ac: 17. C'.'_'O s ic -,~ ( icse s - ck •'T'Q from G-c rk) \ ~ 1(

x .

V

J ` on
~ ~/l~ v ~ 1- f v / ._.. ,~ .. -~ ,

~- y

- - -- • 7

S)2*' I M SCORE SHEET

GROUP

StJB

DATE Borg

.TECT 1,70 .

Exertion

COND

• c~ ~ N M Scale

SCORING

1=NONE 20=.\,DDERATE v? ~ I

F-4

'

-

'

E-4

E, O=Nothing

v~ cn cn o i ~ ~„ at all 5=TRACE 30=SEVEI'~E ►-

: °w+ ~w °a

10z`~=D 40=INCAP . 0 .5 Very, Very

Little

COUCH

SPUTUM ~ I ~' 1= Very light I

sUBSTERI:AL SORENESS L

L2=u t

OR AWAR~'=

/ ( l ` ~ 1 1 I l' ' l 3= ~bderate

SORE THROAT

(or HOARS~IESS) Somewha 4 to 5 =

t

. Heavy OF BREAgI

16= -Heavy~

NA~a.L DISCHARCE /

MNC'~STION to 9

tiv r r ' ' Very Heavy ZING

10= Very, Very

Heavy RESTRICTION

~

= ~-- -GUT

_-~~A, , =

FIT

TS ) S~?~ ICNS

BORG EXERTION i' ~

SCALE (0-10)

"' \l

_f symptoms & discomfort

_asted several hours, ";

ou1d they cause you to

/ ia!

Decrease optional or recreational activity Lis t

3 . Take additional medicatio n

7 . Be unable to preform the maX; nn,,,, amo;mt of work that you could normally perform D . Turn this workload level ~disregard fatigue)

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

( occ=ation, schoolwork, critical household duties )

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

Visit vour physic ian

''is it an e r.er~encv room
~i~'~•/'~

C "Wit MEM

•~ _ 7 ~(~ S~~''_ ~~i•_ ~~~..~. 5'r=.=

_ _ v p. 77

~/ t.~ i~- `~ ✓

SM!~.r~'i" NO . ;

F--~ ~CIl COND .

C.': 1 Z.^ L G

N C^

21 1

I-1 1 1 r r _ Sc

~C COP t 'TC E'-, I

C=' f!1 V] M

? 1M.rC. 2J=%?'DFR^-~ C .,

F" t= E•-' C

L 1 LJ ~° 0^ VCi t:~~_n~C

v'

a c c. cn

10=:~ '[ 0= ~~ p 0. S=Ve_,--J_ VEry

COUGH

Sru -Ri'v- I 1= Ve=y

C" '==' '~ _~~

.~•_- I ,

..:

1 ~ I ~ ~ I 1 t\ ---

; tli ' _

--*_f~

r- t i t -

-_

(Cr t

: ~

= ~

•.---

_ _ • I f . ~ ~ I ~ I t

. -

_

=_L'L~ .. Cr

I I I \\\ ~ i -

---

_ti

~ tll i ~

~ lll ...-

---

~l~

_~~_ 11 1-51

__. ~_l. '. a✓,r \-c ' ~ ` ~ I ' 1 ~ ; ~ ~ I i i '

; - .,- -y._,

-_-= =

= ~ t ~ ~ 1 I 1 I 1 1

==-==_=~

~_-~ ;~ \ i~~ ; 4~~ ; ; ' ;

I1II

_

•,- -' I ; • -~ ~ ii i

\ ~~ ► ~ I'D ;~,b~~~~

s,._,t:--, &

„t I

,

-------- -- ------ ---------

---_

asted several 1-.01r-s

,culd t:`iey cause you te I l t

Decrease opt=ornal or recreational activity Lis t

Take additional medication

Be unable to preform the ==.~ =-cmt of work t :LLf-1t you could nnr~? iv Fe=o=

T = - this wcr:`clcad level - E E fat_o; ~e)

. Be t~-r:aD1e to pez=or:n yo= Usual work activity or level of produtiv t~

cc=.mat_cn, sc:.colwor:ti, c -4 household duties)

S L`.77 at home (lose s=c-c f----m u;~r_c)

~/ ;5 :. = VCLL CCl`jsiciar:

V

,

~ ail ~ or p C L' . .='
. U-

. I p . 78

~ P,

F1,

S'u'B.TEriR~

, 1 t

DA'i'F' ~~j t~ t Bcr,

'!! C 2 z E:~cr ~_on COND ~tt t . /

C

~ `r" C14 c r, Sc°? e

Si.ORENG

z! cn01

U)

1=~-\AME 20=~DDEF ^-_

= P-, r-4 I-, C1

' 0=~7o t'7 j Q

Cl) v] c!1 G t l 5

. t c Ct =?~^•_CL 30=5`U~'4 ;=, v~

10-~.+i ~JO-_:Vl~p .

1

0 . 5 ve-rl

tt _ l f ~ l ~ / l 1 tt

Z- VE'_"'7 1? Qn L

~J~

:~~,.?'i^T

M

. S-0=

_~S

2= I1V~L

:P. :~~~~:~ / I I I 1 t tt t J I~ I u-~==--

C- ZlkvC

:~V

~

.~ ~_-- _ I ~ I/ 1 t ~ :~---

._r.~~{`.;.: '

_~ ---

^ _ ! / ~ j ~ I ~ ~ I ~ 1 1 1 } i I ~

tr~

_ _ ~ ~ I t t t ~ I I i i! !!t l ~ , ~i _

~~ C

-_ _ ~ ~ I I I -

.. ~ ~

!._

-

_

17

~ ~ i ~ , / I 1 ~ I ~ `7

I I ~ III ~ ~ i I I 1 I

--~-_-

----- ; ; ; ~

7

I

sti-G?JLCuS d1sc,~:~orL

asted several ho-L=.s,

:)ulci they caus e ycu to

. Decrease optional or recreational activity List

Take additional! medication

. Be unable to pre=o= the ,mcmt of work that you could normally Fe-r:-O= Ttimn this workload level a-z disr`gard fatigue)

. Be unable to perform your usual work activity or level of productivit;r occ,mation, scIn-col: ork

, C--tic--l household duties)

Stay at home sic'--c (lose sic~ tl*~ from G~r?c)

. Visit your phys_c~.n

Visit an c~r rc-; rc,=
p.79 1`j~533

GMvP y -

No .

DAM

COND ..

~ ,

( C^1 1 1 z G L~ y

.,y r+ N c11 SC.=~ = -Cop-,C- I-C-- ~ l

z ~n x ir •_

.

: ~-~~ 1 ~ ~ ~~

v c+ c n

= at `~

5=' R?_C~ 3G=S=.vE-'=

~>c r- r c_ ~ v' "' c t r t~ cr Cr

vn

Q<J=IE_'_j,V=~

CCliCi tt ~ ~

.

.c

"rLiU W- ( I~` rrt 1= Ve=; L~~t

sD _ r . Ll

1 I l r-~ Ll ~.~~~~-_`~.~- - I/a~ ► 1~1~1\ ~I~,l ;~ ;~~i u__

~ i I t r t ` _ _-=_=(

(C'-

r

__ C'

Ilt

~ C=

~ ~ ~ ~ ~ ~~;, ,~ ► 1 ,-

',•r=-==~~i: ~ ' , ~ ~ r_= , =_ -,

`~_-- ==--__~~-~~;

~ ~ I y i~ i ~ ✓ ~

'D ~ ~

rb

C.=sC .=r-z ►

-q t: Zia S2ver'l ~'1CL.5 , ~ t

N-ould t_`iey cause you to

/.

.

.~r7r ~-• ~ _ ;7~ 11~ I (

. ~ ; I t --~

' . /

-k . Decraase optional or recreational activi.t-j List

B . Take ac.dit;ona.l ~edic`~on

C . Be unable to pre=o= the m~~~sn =omt of work Lnat you could ner~ly perform D . Am tljis wor:t cad level cou,~i (aisre~a.rd iat~ m~e)

E . Be t naoie to Perform yet= usuo-1 wzDr~_c act?vit•j -o r le~~-el of productivit•~

(W ec_.~at;on, s~ col~~~r_ti, C---4 t--4 ~ household e:ut_es)

Stay at home s--*c : c (lcse sick ~ i=cm T~; r_c)

V~s~_ ycur ph•r~~c~. .

V_s :- _ ~n eT°r~~re s~ t
~ p.80

----

c.ti~ j~

(C/

~

tbv~t t_ Rvr=

COL~{!~ . 2 t c l- SC

C E--r

r N C' 1 1- t t ~_ ~}+ z- °

1

~~• z cn cn cn x: 1 •_

r. 1= r F- N }-= c*l G= I Ci Cj

20 DE=;=

i = c c. c t r , 0':c

77 cr. cr_. tn r -' - a_

C 1 t = C C='

.,~~ .`~'- ~ ~ ~.=-' ~ ~ «~- ~. F- •~--.+

r t 1

.= _;

2

COLCM L .Li=ve7iigic

rtt __

U

'

- 2

~ _'~.

f , ~\, t , tl 1,{ J

' 1 f Itr ~, ,

•

C' 1 t11 I ,

~ . • , • ~ 1 1 ~ I ', ~- C- ~

. ~f~ _~

_--.~ ~.~~~ ~~~1~ ► ~ i\I~ Ii~i~ll~li v`- ~ _~. _ ^,_ ~•~~. l ~ ' ~ , ~ ~ ~ ~ = _ _~.__+-~~

1 I

i i !II , __~ _ ~_-= •~ ~ : ~ ~ 6 ~~ ;,~ .

0

+s ~~ ~ s~~rer=? hcuzs I,

~7 ' Itt

t

CLV ti7e,7 C

_ ~ t t

a-L'S2 You CO 1 1 t

- --~

Dec=ea-s z onciony1 or recr=~ticr a~ l ac~.viCT Li ~

Take ~ ~~ ~Ci1~1 II~~ C_t=CL1

Be L rLHe to pre-F0= the IPx ~' _iT1~`1 cuCUZlt of CvZ,'r:: t_` a- VGLL . COuLd P.L)r"._~1 ' ly per=:,?'.1

'Itis.i this warc! cac 1E re1 c~Y~ (~sre~~ra fat~~ e)

Be t~+_aD1e to perform yc= us-~ w~r:c ac~.-._j7it,r or le•:ell of procu~_tizt~

~~ CC= Zct=GPi~ SC .^^1~vi r :`, C;~=C?~ ~ 1CLe. .710! C CUCL°C)

Cirv on h C = S C:C ( ICSe Sick t-- ~° L Tfl *~~~r:~ )

V-: CC:YS:-C -- _

V~ S ~' w . ~ °'""o^C' _ ~C•:T!
p. 81

2-

/T- 10

,/)
p. 82

~ STUDY NUMBER STUDY h'U"SB .-- R STUDY N

:m

:m ~ io _o O im c7 rn "I ~•

o .'~ y ::~ SUBJECT NUMBER SUBJECT ATU!•:B : R io cn -~ -- ~ c1 ?v SUBJECT

t 'o o o m -c

- I I N N (/)

•-~ --~ -i- Oil

GROUP NUMBER GROUP i~TL__EER GROUP NIT~SB n ~

:R

?~ ~ I I I IJ CARD NUMBER CAxD NU*1EFR C~~D

o tD { I~+ ta cn NUMBER

~

Ea H

J I I I I _ IREACTION ORDER REACTION KI I PEc~t,~ FEVER 7' v

~ +--~I--{ I I I SEZ':RI?'Y SCOP.:

D _ f~l S~ SION

1 Pr.C?A'T iTF_ ~r-INP

I NL?~ Or . f-~I D~ OSUP.E CODE ;-I { DRUG

T TACI:S lc- I~ I D:Y OF k-~?R fOi~ { f I A',S 7, )

-t-T-! I I UPPER R .

IC i~ OF DSY INF . ;<•I I=P,EQ

TL*

,

COU :,H ~ .~ DP.UG SUETCT TYpE

~

f~ I i I I 1~1 i'~ ,AL

T

~

'=1 ~..:o . I S~XD cl

.ASs

----------- ------ I

s„E I I-t-I- I 1 f , t=f DP.uc

S UB . S T:P.2~4L "' I I-~

SOP,.?i~~?

I ~ I I I I (~_ I~ SORE i"~

s

S I~I -REQ

;Oi_T .GIiT

DRUG ~~ n' ) F----{--i ~_ ~~I tI

~

i---I-- f-t- I

I I I I I

(-n

1- I I I~ SOB Q

. hF-1GET NocT . (1 D s.)

I I I I I I I __

OR'3o?N EA

71

I I- RUNNY NOSE ~':) I>> Cr..."-.ST ILL/31F,

~ f~ ~D O { L

010 t~ I I

{ IDLN ;

RCS? IN P~ ST 2~~ P,

:J

{

~= ":, E: s =us C_1 P:SID~N c:. LENC.

_ !C^-T~ N-Z ss i __~T ,~- L P___ LOI-:...

L I I I- I-I~:~o I I C~ ---=~~v^~ ~ T RA-T-- I

---{Cl O K~ f01= l- T .

:~cl~J ~

~oo~/ou_UOO~

I I I I I I I I 1 I~ =--~ ^~ ,- { y~~ '" ~ occU -ION

1~ I IO ~._ .

. t *~_t~~_ jOL ~ cupr ~ .INC s<<TLTj I~_~ DPI~__10N ~-I - REST

I I I I _--~t~ QT~ 1 ~ j .R T

piI2\7U

T7 VOLLTMi E

- t~ ochCram { PACK - Y:~~S

s ;-I ~~CISE

~ ~ i -~ ~ N ~ "'y, ~ r~ ~ ~ ~ • I I ~',~~, ~ - -

I C/o SOB "I '7 i J = }a's I

I ~ r ~ H ~ T r JI ~ Q. OF ~ Lk 1 e1 7 =v .-Y

Ln LO `IJTOI''.Y tn .-..j '",

; -j vn y

o M

~ I {

E=STODY

~ ~

~ ~ ;~~ I =S~~LY

... I

li

~ -

S :NSITT_~%=^'`

P.FSaOP;SE { -

i=1 I I 7='-'/

T17

--` ~ ~ -- -

~ I ! I =N
. 8

3 C1~ STUDY NUMBER STUDY NUMBER STUDY NIP..ig

, ,

. . ,L. J o ^ o

•~ io 0 o im c~ m "I

o ~ SUBJECT NUMBER i7 SUBJECT NUMBER SUBJECT A'UM B io cn ~o o 0 : ^ I IN [.1) V) 1L7

GROUP NUMBER GROUP NUMBER ~ GROUP NUMBER

` la cn I~~ CARD NUMBER CARD NUMBER CARD NUMBER

o -IN

REACTION RECENT FEVER 23 SESSION ORDER

SEVERITY SCORE RECENT UPPER-INF . N EXPOSURE CODE

NUMBER OF DRUG I DAY OF WEEK

(QI~ ~ ASTHMA ATTACKS TIME OF DAY

- I- ( 1 UPPER R. INF, kl FREQ. n

-IO~O COUGH ^I ( DRUG {- -~ SUBJECT TYPE

`~ COPD CLASS

~ ~ SPUTUM

O~~ ~~~ ~ DRUG

FREQ . SEX

AGE

1-1-~. ~--- I I ISUB. STERN_,I, ~n

1--F--10 IC) 17 Id10) -f- SORENESS ~I I FREQ. Io HEIGH (in.) ~ + I ~ _ DRUG

+ ~

SORE THROAT I^~

I-~ I I

I SOB -') FFEQ• C` WEIGHT (lbs.)

-

F--) ID I

L

Z~ I NOCT. ORTHOPNEA Io0

I -- ( + T~~ RUNNY NOSE >> I I CHEST ILL/3YF, RESIDENCE f

`-j~ HOSP IN PAST 2YR I

~ I ( li"~~~ I WHEEZING I WIWEZE/Rk.LES AUSC . T = ( R:S_DENCE L ~ . .h~T

=+--7H 1 t I

CHEST TIGHTNESS ~HEART RATE REST =,17 LOCALE

~ ~ ~ ~ I ~ I I ~ N~f FyTIGUE .I- h:,AF~T RATE, I INDOOR/OUTDOOR

EXERCISE

HEADACHE OCCUPATIO N I I I I I I !~I~~ {~IC~ I `

I-~

7r

~~ MINUTE VOLU?~ H

SMOKING STATUS

~

~_ .~ EYE IRRITATION ~~- REST

- OTHER MINUTE VOLUM £R CISE PACK YEARS E

: R

, ~ + I ~~ I IWHi:.ZE

C/0 SOB C PHYS E X

irrl ~~~ H` y I m n ~=I !Fi'.£Q . OF ASTH?LA ALLERGY

I ATTACKS NO /YR HISTORY

SELF

C

) I y y

y ~I ALLERGY

1-3 HISTORY

FAMILY

y

SMOG SENSITIVITT

AIRWAY RESPONSE

~'~ l I EX'_?./INTP,/?!'I}.r,D
p. 84

~ -.~. STUDY I~tJ?SS'3 STUDY NUMB=3 _s'_ STUD

Y •-I V~ ,

iw N j-' ;~ = ~ • •)

i°

52 CD r.1

q SL?j-- CT NUMBER SUBJECT ATU:.IBDR SUBJECT 2\rLj*_iSr3

0 0 :- rn ~ ~t

{ I. icn cn cn 7 ~

.-{ ---! - )

NJ

GR OUP NU*iSDR -J GP.OUP NU?~R :~ ~+ -p Gr,OL_ U?~:

7R

L f J ~ I I I C_°-F.D NU*"3ZR ►~ I c.~RD N r1S: ~ C ALR D NtJ.v.B=_ 3

4-• Io l~ h Io, !~ ~ I n~

I f ! ) ) f REACTION Kf IP.s,CL'NT --EVER I ---r2sS:SSION ORDER SEVERITY SCORE I RECENT UPPER-INF . 1 EXPOSURE COD =

I NL-T"~-7=R OF

j

DRUG WI D_Y OF K ~

AS=•1*~4 I CF.S rl 7,~r ~yy

_ ( ( I L~DF_~ R. INF .

TI-ME -OF D=Y

I COUGH DRUG SUBJECT TYPE DP.DG SUBTCT TI-Dr

COPD CLAS S

1~t~1 I I I _ SPUTUM ;=1 :?.=0 . S7_ X

DRUG AGE

I I I i I I I i SUB . STERN-5I.

SOr..'NESS r-I =R=O. f -- ( )

l~ i f I I IN SO?,: TH'.0_s r,f DRU G

-

I < ZSI 1~ )

I I I I soB I F7RWO . wzIGLT (?*Ds . )

NOCT. 0R:"30P2v:,A

~I I i I I ~I - I~ P.Uh NCS: Lul 1>> C'ST T~.L/3 _~'i, ~ ri-

~ \t~f I ~)} L~~ HCSP TN P

A

ST wR f

_ ! ( ! f ~ i f ! { w__. ._?rG 1-1 ! Lr:F ..._./R-TS AIISC .1 RE- S 1DI 3NC= LE. '

p

~s

^'•=

_

I

r

_ I I I I I c~s~ _ c:~r~ss )y ) -A~^ ~~ P,7 ,l F w'0? ~ LO ` .

___ G~.. . M 1 La1 )~.~ D ooK/

I~J I~\T~'~'1 ~ '-T~ 1~ ~ J ~. ~•^?l.T.~. .r

OUT D ooP

-!ON

_ y

~ , I I I ! (N~ Ac=--

lc~N1 ~'-1,---T~---i--T-`TI . I

{

I I ~_ ) ~`Z~ VOLUME ~~o,~v S=S

-_ ( I I I )LEE s`~.. .P.I^ '""TON REST

~ i I I I I I -I I OT= *=1 zN~= voLU~ ~ - ------- ~~- PACK Y,- Z

_ ^ !ZI I C/O SOB C P7-°S -v f ) k'u I ...n

r_- I

< -M

0= ec_?re I A

T7=~GY

-'~-~ -"=i^i.S NO/°R ~'ZISTORY

zn

Ln --~--

~ ! .~: o s1 . ~ r=+

.y

CJ H ti eT .-r -p

~-= `-'i RT_STORY

cn

-3

= _ e u 1,Y

IT_IGIT?I

bI F,;a _V P. E S 11 Or;S Z

"- ( I

'=i I I 7=/

7

: / 2~= 77-D 1
.85

STUDY NUMBER STUDY NU*1BER STUDY

f ~ iw tv'~ o p

. . .

."f- -

1m o o im Q m

SUBJECT NUMBER SUBJECT NUMBER SUBJECT

io ~ ~

io m

I i(ln ( ./) N' G7

--~ --a - { - f~

GROUP NUMBER GROUP NUMBER .~ GROUP NUMBER

_ -~ ! ! f ! f f CARD NUMBER CARD NUMBER ~ CARD NUMBER

f~ 1 o I ~o Li la 1 cn f~ 4.~ ~ ~(r, ~

f f f f ! f REACTION tZ) f RECENT FEVER }~-! SESSION ORDER

~---~I SEVERITY SCORE ! I RECENT UPPER-INF. 1~I EXTOSURE CODE

(' ( f NUMBER OF DRUG ~~11 DAY OF WEEK

!Cj f0 ( ASTHMA ATTACKS (ZI TIME OF DAY

I-- f--I I I 1 UPPER R . INF. ~I - FREQ.

( ! ( fICOUGH I DRUG (-~

IS

SUBT CT TYPE

i 1 COPD CLASS

I f II+~71-I I I SPUTUM I FREO. NI SEX

I` f~S l01 ll! 1=1 DRUG AGE

I' ~I I I I I SUB . ST ERtz9L

SORENESS "I FRFO . HEIGHT (in .)

I I I I I (~_ I~ SORE THROAT ' ~L ~IDRUG LN

! f- I I (~ SOB FREQ . I-WEIGHT (Ibs . )

NOCT. ORTHOPNEA I(`~

I' I I I I I ~~ RUNNY NOSE 1 (>> CHTST ILL/3YR R .ESIDF.NCE

_~7!'~~lU~!~(J' ~.5; ~CS !~ I HOSP IN PAST 2YR

L I I ! I I I I ~ WL- .-zlNG 1-1 WL=.~zE/RAi.:.S AUSC .1 I RESIDENCE IEN' ( t- -- ~-~-.1 T lCT~ i ~ -}_- ItI -----~

I •' ~ I I- C=ST TIGHTNESS ;=1!~ ~~;..DT P A'_TE R:ST WORK LOCALE 1~~--- I--I' ~ I T41~, I•- I-~~ ~-z i=

L I I I I'- II - I f ~__IGU '"

El

~.~RT R__TINDOOR/OUTDOOR

I C} I EXLRCIS:

. OCCUPATION

I ~

~~ *iI21UTE voLLT-1E SMOKING STATUS L I I i I I I I I~ E?',- IRRITATION PEST H

Oi'~r=:R =1 , MINUTE VOLUME PACK YEARSj

~H fI I =C I S E - -

k~r.: ZE

I o n' `1_ 'b b o " t=1 I C/O SOB C PHYS EX (

< %~ m OF ASTu*1t~

77 T6.LLERGY

~ o +ATTACKS NO/Y"R HISTORY

°

Ln ~s +-3 zo S -.T F

-~ + y ~. ~' o rl

H rnH ALLERGY

-3 HISTORY P

li

F-3

~ ~v 1 S*10G SENSITIVIT

~ ~ ~(

- ~~

`r' AMWAY RESPONSE

: ►

~~ . ! 1 I_SP3 ~N
. 86

----- - ~ r ~~ f

~1 4

STUDY NUMBER STUDY

-~ ~

NUMBER STUDY"

!w N

im - -(-

; 7c io 0 o im

;" s

n m

lo

;o ;:o !~ BER SUBJECT NUMB SUBJECT NUMBER SUBJECT NUM

: 0

al ~ ~

0

+ I~ !N N N 7L7

-1 -~ --~ ----------------------

~~ J I+I I GROUP NUMBER =1~ GROUP NUMBER GROUP NUMBER

(~ -~ ( I CARD NUMBER CARD NUMBER CARD NUMBER

IC, ~-4 la cn rv --d

I( REACTION ~ RECENT FEVER •J SESSION ORDER

SEVERITY SCORE ,I RECENT UPPER-INF . EXPOSURE CODE

NUMBER OF I DRUG DAY OF WEEK

ASTHMA ATTACKS (z~ TIME OF DAY

1UPPER R . INF . k FREQ . HI

t-1~- COUGH DRUG SUBJECT TYPE

f--~~-~~-I~ t~ COPD CLASS

SPUTUM I FREQ . I SEX

!~ I DRUG AGE

I SUB . STERNAL r H

SORENESS i< FREQ. HEIGHT (in .)

+ I ~ SORE THROAT DRUG

SOB FREQ . WEIGHT (lbs .)

Cl-I -"~-~ I ( NOCT. ORTHOPNEA

~~ ~- I I I ~ RUNNY NOSE ".l 1>S CHEST ILL/3YR P.ESIDENCE

HOSP IN PAST 2 YR

I I I I_ I _L~ WHEEZING W IEEZE/RALES AL'SC_I P.rSIDENCE LEN ;,_E

CHEST TIGHTNESS I-- I Hz-22,T P-kTE REST WORK LOCALE

Iclaiol kl

FATIGUE r.ART RATE I INDOOR/ OUTDOOR

E}ZERCISE OCCUPATION

► I I~~~_ ~--~~ ~ADACHE ~ I • `

*1_ :VLTTE VOLUME- SMOKING STATUS

EYE IRRITATION REST

JOTEP'rR MINUTE VOLUME PACK YEARS -`~--~"-- I ~ ~I E

>_-~ --- ~_

X-ERCISE

I ~ ^ ~I I WHEEZE

_ !o ~ o - I-< I I C/O SOB C PHYS E X

Im o I o im m m FREQ. OF ASTHMA ALLERGY

No SELF

o

ATTACKS NO/YR HISTORY

--i I o 0 0= , n ~ o ir

N N (!)

~rLl ALLERGY

HISTORY

f~I FAMILY

+il I SMOG SENSITIVITY :

{~I

I 1AIRWAY RESPONSE

1 -

~~-:

1
STUDY NUMBER STUDY NUMBER STUDY

- n 1w no 2 w'O O

o o o 'r" r' ^'

1~ i

I ;=C C

~ -

:>< y`~ SUBJECT NUMBER TIN SUBJECT NUMBER SUBJECT NU*1

-0 -.0 C

D

~-N-I I- I

M ;o

, • GROUP NUMBER GROUP NUMBER - ! -:1 GROUP NUMBER

~CARD NUMBER CARD NUMBER ~ CARD NUMBER

o I'D lco ~a ( m rv

REACTION l I RECENT FEVER SESSION ORDER

SEVERITY SCORE ~ RECENT UPPER-INF . EXPOSURE CODE

NUMBER OF DRUG (~I DAY OF WEEK

ASTHMA ATTACKS rFZ-'~ I~ TIME OF DAY

!~_F- UPPER R. INF . I FREQ . 17)

COUGH DRUG SUBJECT TYPE

I COPD CLASS

I I I

&1+AjTT-pd

SP~UM I FxEO . I'~ SEX

!f I DRUG . ,,N AGE

I ~ I I I I_f _ I S UB . STERNAL IN

SORENESS ELI FRE0 . HEIGHT (in . )

i I _ ~ SORE THROAT DRUG

Q!)

I` SOB FREQ. WEIGHT (lbs.)

Fn iO' I--r-i- NOCT. O:,:THOPNSA

I I I I ~ RUNNY NOSE 1 >5 CHEST ILL/3YR ► P.ESIDENCE

~~~ ~ T~ HOSPIN PAST 2YR

~ I I -- I-( ~ WIFEEZING WF-.;:EZ:/? -A_LES AUSC .I R.rSIDENCE LENGTHTH k~ I~I ---I- ! C~~ ( d I--;--r- ► ~ I

CHEST TIGHTNESS =k :T RATE REST WORK LOCALE

FATIGUE HEART P~.TE IIv'D00R/OUTDOOR

rX.*:RCTSE OCCUPATION

(~_J__ t I I I I HEADACHE ~

MINUTE VOLLTM' SMOKING STATUS

EYE IRRITATION REST ~

t~l- ~I'Id~ I

OTHER fl MINUTE VOLU?,FE PACK YEARS

EXrRCISE

I i +- WHEEZE

! C/0 SOB C PHYS EX I

'T' FP.EQ . 0 F AS T?n.T e ALLERGY

I~, o o ~ I ATTACKS NO/YR HISTORY

o , t'~ I SELF

C)

,3 HISTORY

y ALLERGY

i

-

CCl1~7 y

) FAMILY

I

y ~

SMOG SENSITIVITY

H

AIRw_.Y RESPONS E

-~ `~ I ( EXTP. / INTR /MI`-D
-;~?.~o•'~ _~c°_.t",' ~

STUDY NU'.11BER STUDY NUMBER STUDY NU*iBER

O O ~

x io m c o

-) m

:1:1

o'~ ~~ SUBJECT NUMBER SUBJECT NUMBER SUBJECT NUMBER

O O O

:^ D ~ -~fl

GRO UP NU?~iBER GROUP NU?SBER GROUP NUMBER

L ( I

H

mv--j

CARD NUMBER CARD NUMB CARD NUMBER --R

I-~ t o ~ l~ ta t cn ' _ Hr,

REACTION I RECENT FEVER I SESSION ORDER

SEVERITY SCORE r,I I RECENT UPPER-INF. Z :,q E)2OSURE CODE

I~ NUMBER OF DRUG S~:) DAY OF WEEK ~tQ t t t t AST'L_*1A ATTACKS• TIME OF DAY

i-- I- I I I ( I UPPER R. INF. ~I FREO . t

~_~~ I COUGH ~.~ DRUG ( I SUBJr..CT TYPE_ .,

i I I I i I I I ~

t I CoPD CLASS

C . TC~ I-~s1I

sPUruri FR E0 .

t I AGE

SUB . ST ER2z4L H

I I11-'I~10 I SOP,EIv-- SS :t l I FR;Q . H: IGHT (in .) I% ~ I I 1 I ~ i I~ SOFE T'tOnT DRUG

I~SOB ~I I~WQ. WE'IGHT (lbs.)

I NOCT . OR _ HQPNE9 1

i~f_ i I f I I 1 RUNT;Y NOS EE ~,I I>5 CH:sT !LL/3 ~

~ t IU~_I ~~S1I ~s~s ~ P.:sIDE r~,..,

'1 I HOS p_ IN __

_

_5T 2 Y R

~ f I I I I I I~ ivH.,_ZiN„ -I I AU ..

-

fyl SC.t P,:S_D:?~C LENGTH

I C r= ST TIGHTNESS .=1 T~'AFT RATE REST WOF,K LOCALE c1?

~ li ~ I I-I - I~~ I i ~ :STIGUy , .1 HEART RTE I2\ OOR/OUTDOOR

~ ~~

.

~ ~~--~- S~ EX✓i2CISE OCC'j-DAT_ION

7-' I I~ 4 ADAC~ ;,,1 ~ •

il +- _ HM T_IVUTE VOLUME C 7,~ OK_2~,~ STATUS

EYE IRRITATION til PES T

~ ~ ~ ~ I OT~:R ~=) *1INUTE VQLU W PACK r `~'-~ ~ .

. AY:AP.S

fI EXyRCISE - ~ - _

n wl

I kr .ZZE

I C/O SOB C?HY S EX 1

I i~ ~~ = H , T w`.~ :P.EQ . OF ~wT ~,re t e1IE?ZGY'

'"TACYS NO/iR HISTORY v' It

I N I -t S~ ~ < ~.

y ro f

o tn ~i

r-3

L-,' f' o

ALLEP,~ _

HE rSTpPv

cn H FAMILY

~ w -f I ~*10G SHrSITIVITY~

I IR W A Y RE S P O N S E Y
` •~ ..J

.'

.' lilmillp

(-P STUDY NUMBER 1STUDY NUMBER STUDY NUMB -

:m :_ .

_ •-- o w rv i~~ o ^ o N . .

iCD 0 o im c~ m ~'1

ix v Ic I c .x SUBJECT NUMBER 15

io o~ SUBJECT NUMBER SUBJECT NUMBERra -c -S)

lo o o :-- m

N N V1 'L7

I ~

GROUP NUMBER GROUP NUMBER J GROUP NUMBER

L -~ { I { CARD NUMBER CARD NUMBER CARD NUMBER la v, A(.~ {N

( {(( REACTION ~Z{ RECENT FEVER 6ISESSION ORDER

( {~~ { ( { { { SEVERITY SCORE RECENT UPPER-INF . {EXPOSURE CODE

I{ { I{ NUMBER OF DRUG

IQ)'l

DAY OF WEEK

ASTH*SA ATTACKS 1z --~

TIME OF DAY

F~ I- I 1 ( 1 UPPER R. INF . lk) FREQ.

12: 5

TICOUGH `~ ( DRUG -4~-- { SUBJECT TYPE

I COPD CLASS _j SPUTUM i FREQ. { SEX

DRUG W A GE

~ ~ ► I- I- ~- ~ SUB. STERNAL ~ ., H

f 10 a -}--- SORENESS FREQ . 1~. HEIGHT (in.) I { I I ~~- _ ISORE THROAT DRUG

SOB { FREQ. r- WEIGHT (lbs.)

:~ I NOCT . ORTHOPNEA { K1

~ 1 I I 1 I 1 RUNNY NOSE `:{ ~~ CI~ST ILL/3YR { RESIDE NEE

~` '~711 IHOSP IN PAST 2YR { ~~ I I I f I I I I~ WHEEZING I W=- EZE/R4LES AUSC .I RESIDENCE LENGTH

CHEST TIGHTNESS HEART RATE REST WORK LOCALE 17)

FATIGUE HEART RATE INDOOR/OUTDOOR

EF.:.

.'RCISE OCCUPATION p I~~ I I I I I ~~ HEADACh: ~ . -

*SINUT':. VOLUME SMOKING STATUS

EYE IRRITATION (- REST H

OTFER MINUTE VOLUME PACK YEARS

EXrRCISE

I 1 'c{

1

kTHEEZE

~ `m I~ ,, p

H FREQ

O~_° I~I I C/O SOB C PHYS EX {

. ASTHMA { ALLERGY

o

M

ATTACKS NO/YR HISTOR I Y Lo

~ cn -1 0 H `17 ~ r=1

°

HSELF

I I ~" o

co c

y ALLERGY

n

HISTORY

cf]

F-3 auiLY

F-3 -*z

SMOG SENSITIVITYf

v v I~L~ AIRWAY RESPONSE

I~I ( +

l - ' t~'77P / 7t^rn ~Mr~-n
=61BER

-

VSUB

NL?SBER STUDY STUDY NUMBER

-- o i w rv i = o •.-~ p

;m o o im c~ m

~T NU*SBER SUBJECT fiUMBER SUBJECT NU*iBER

C) C) C) m

m

GROUP NUMBER

GROUP NUMBER v GROUP NUMBER

L -1 CA

=1 v

RD NUMBER CARD NUMBE R

a cn -:I,. CARD NUMBE R

( REACTION RECENT FEVER

I- I- ( SEVERITY SESSION ORDER SCORE I RECENT UPPER-INF. E}-,pOSURE CODE ( NUMBER OF DRUG

10 I01 I ASTF.*SA ATTACKS DAY OF ky -K

~- t-- I I UPPER R TIME OF DAY . INF . FREQ.

I ( ~ ~ COUGH

HI

DRUG I SUBTCT TYPE

SPUTUM ~I CoPD CLASS

l l I I I 1=~ FREO. ax

DRUG H

AGE SUB . STERN_ L

SORENESS 1Z.1 ~« rQ . i L.

( ~- I I ( _ SORE T•rROAT P,i DRUG -~-~ZGHT (in. )

I I I I I I I SOB =^~ ~

I --rT"Q'WEIGHT (1bs. )

~i ( I I I I ( I ---~ RUNNY NOSE "I INOCT

. ORTHOPNEA i

P-'I 1>5 CHEST ILL/3YR RESIDENCE

L I I f I II I ( I '^ I HOSP IN PAST ZYR I

Ty=- :L1N;, IWIE ZRA.L?S AL'SC .

I P,EsiDENCE I;N;,=:

~ I --------------- I

I I I I I I I CiE-:ST TICHTN'~SS 1a-4PT R=^ REST WORK LOCALE

i i i I-F- - I I ( ~ FATIGUE ErART P~~TE 7T~----~-~ INDOOR/ OL'TDOOR

OCCUPA_ION

I d IC~ I~J~ 1~ I C~ i o IU~ I~,J I~I MINUTE V OLt_~*~=- _ ( c*;Ot;IN~; STATUS

I i~-i-j -- - ~ I EYE IRRITATION tii REST

f C~~ S I I I I ' ~ IER MINUTE VOLU'-kf-r PACK YEARS

Ep'' RCISr

+ ~cI

~ m c

1 C/0 SOB p:.n'S EX

-REQ

. OF AS'Iu*?4 I a.LLERGY

~ o I N o~ ATTACKS NO/YR HISTORY

~ I -~ U, ~ • -7 Co o S--

_

O

~

eZLEP,GY

~

`n HISTORY

F"':iLY

SMOG ScRSZTT-U~-_ T'i•v

RF~r~_ Or D '.s E

,

~_~ I

.:

^~•.

.•~ ir,-•^~ i~,__.-r,
.91

STUDY NUMBER STUDY

_ •S--~,

NUMBER

iW N1= 1~ ~" 2

o o '3 Ei m m

SUBJECT NUMBER t SUBJECT NUMBER SUBJECT

o N , -~ ~ ~ ~ •

~ io o o

Il7 N 'G7 I

:-~ rn

--

1 -i -~

GROUP NUMBER GROUP NUMBER -- Z) GROUP NUMBER

CARD NUMBER CARD NUMBER CARD NUMBER

L J J I

4J O l.O h7 I~l I CT I'~ L~ N

J

T-1 L

REACTION ~j I RECENT FEVER SESSION ORDER

SEVERITY SCORE ~-I RECENT UPPER-INF . -~ EXPOSURE CODE

NUMBER OF ~.~._~ DRUG DAY O F WEEK

ASTHMA ATTACKS C~ TIME OF DAY

~---I I UPPER R. INF . FREQ.

COUGH ~ DRUG SUBJECT TYPE

~Z

rt

F~F =

_~n~~_I 1 COPD CLASS

~ ~~ ~ sPUTUM FREQ . SEX

DRUG AGE

I I I i I I I I SUB. STERNAL "I 'v iI

SORENESS "I FREQ . HEIGHT (in .)

SORE THROAT DRUG

j-- I SOB I FREQ. WEIGHT (Ibs. )

!{ p ~--}- ,:-] NOCT . ORTHOPNEA ~L}1

~ ~ ~~ f-- f--- I RUNNY NOSE I >> CHEST ILL/3YR (f RESIDENCE

10 Irl HOSP IN PAST 2YR

L I I I I I- ~- ~ ~ WHEEZING WHE- EZE/RALES AUSC . 1 RESIDENCE LENGT

HEART RATE REST v70RK LOCALE H CHEST TIGHTNESS

I--`F- - - :747-

FAT IGU

--~ ~t-

~ E HEART RATE IINDOOR/OUTDOOP,

EXERCISE OCCUPATION

I I I ! i I HEADACHE

_._,{~~ ~ ~-~ ~--r-r- EM ~ MINUTE VOLUME SMOKING STATUS

EYE IRRITATION •~I _ RES

OTHER MINUTE VOLU T ~~ ME PACK YEARS

EXERCISE

_ I ~I ' I WE.:EZE

I ! ~, o o I o - I^I I C/O SOB C PHYS E X

- I ~

U) I= r'"'FREQ . OF AS Ti?*SA ALLERGY

7Z r-1 T ~ I 1 ATTACKS NO/YR HISTORY

o ° --o

t=1 SELF

"'

ALLERGY

v~ ~ ~' HISTORY

FAMILY

SMOG SENSITIVIDAIRW__Y RESPONSE

, ~ .

1=1 ( =7" -D

: .I I ASEIP, =N

-i ~ I nT Th-7r,'
92

STUDY NUMBER STUDY NU11g

IW N ,0

:rn

~ O o~ o m m

i-fl ~c a .~ CSl SUBJECT NUMBER SUBJECT NUMBER

io °

o o m ~

N (.!) N

GROUP NUMBER GROUP NUMBER

t _~7 G$ptJpt~

L J I.r I I CARD NUMBER CARD NUMBER

o I o

( REACTION tZ I RECENT FEVER ~ SESSION

f-- I }0?URE SCORE RECENT UPPER-INF pSEVERITY . EOS

I NER OF ~ ~p

~ (~I TL*~ OF

DAY OF kT

D

I~I---) ! (

I~J I- ! ILSJ (l~ I- ~-~ COUGH

1 UPPER R . INF . !.t• FREO

^. DRUG

. ~

SUBJECT TYPE

r7_1C) rlD

~ SPUTUM I~ll FREO .

COPD CLASS

SEX

'r---rL--I- !C --~ 757:~C

_

~ ) DRUG I-~ AGE

_ I I f i I I SUB. STERNAL I Ul

[\ ~ ~ SOREIv%SS ( FR;Q . (~ HZ- IGHT ( ~ n, )

SORE DRUG

L

~

-

I I K~~ K~ h K~ IC ~ t~ I

I I ( ! I SOB I FPWQ . WEIGHT (lbs. )

Jl~) NOCT . ORTHOPNEA ! I

RUNNY NOSE 1>5 CHEST ILL/3-n, RiSI )ENCE

~ C'D1 ~~? - I HOSP IN PAST 2YR

~ t ! ! f-' t 1 I ~~`~ WHrEZ1NG j- l ! WH::.EZE/F JA-LES AL'SC .I RES IDENCE LENvT=

~ ~ I i ( ~f CHE ST TIGHTNESS ~.?ART RATE REST WORK LOCALE j'~:

--- --

I N •

I~~ IW j ~- I- ~- I ( ~ F ATIGUE

Effi

1~T R. Tt Ih~D00P./ OUTDOOR

RCISE OCCUPATION

I t ! I~ADACEE : ~,I ~N 1 •-r

1-4- ~ :!l MINUTE VOLL?' SMOKING STATUS

~E TRP~ITATION "1- REST H ~

I

~- E

OTH:R =1 , MINUTE VOLUME PACK YEARS

XERCISE - - - -

`

IC/0 SOB C PHYS EX i ( k~"` E~ ~ ~ C fl o c t_I I

1 m OF

n .. _ i-;

IS :-----4 S ALLERGY

°'d SELF

ATTACKS NO /YR HISTORY

-N-r I~ y ro

*~. ti~ I ~ t C)

O

Ln~ H a1,LERGY

HISTORY

FA.'~iZY

ti 1~ !

y~ i~t SMOG SENSITIVITY,

AI;W.LY RESPONSE
. 93

NUMBER STUDY NUMBER •-<` STUD. STUDY Y

a •

.

. • I~b~ .

SUBJECT NIJ*SB : R U SUBJECT NUMBER SUBJECT NU*SB

o I N° 55

~c oQ ~lop ~ ~:

i L/N [n N

o o :-' m f(- ; m - !-' I •-1 -I --I ' - I~j

1 ~ \ '-

GROUP NUMBER GROUP NUMBER

~- J

~ GROUP I\*U*iBRR

! r (J lJ C-11-RD Nu:1b EE R ;~I cARD NtMBzR Cp~tD NU*t~'R

~- o ~{~ !~, 1~ .~ Lo J

( ( ( REACTION tzI P,: CPNT : LVF..R --'~ISZSSION ORDER

~ SFVrRITY SCORE r, I P.yCLNT UPPER-INz {>,.~ :

-oSUP.E CODr

I 1

NUMBER OF MI DRUG ~I DAY OF WEEK

As??*fA ~=~ncrs r1 =~*W OF DAY

[''~ I ( IUPPER R . Irr' . KI 1 sP.= 0 . {

COUGH ~.) DRUG SUBJECT TYPB

COPD CLASS

I I I i i I`_ -I I~ SPUTUM ------=1 ~.:0 . -rX

;_{ DRUG . SGS

_ I I I I I I I ~ SUB . ST.:RN_9I.

I-1-- ~I--~~- SOP.:r=SS i~l I-P~O. IGT (in. )

i SOREi"~:O.S DRUG I

1_ I-! I I I f~J I I SOB 1---7ap, {

!( NO CT. OF._3DP1~= A

RUNNY NOSE >> C :.~.ST :,:LL/3i?, ISIDLNCS

HOSP IN PI-ST 2-1-P~

w=~IiNG 1-1 I VIE :IP ~ 'S =LSC .1 ~S~INC= L=N.;_.

- til ~

C-- :%ST =ICHTT±SS ART P.,_ ~ Bz ST W0 I _,R~ LOCALE

I

O~, 1 _ -- _IG~ . -{ a:T R:=Z { ( _.~~Ou? -OU=D OR O -

I 7 .:

.RCT-,

. .

1 0 C .C'.~'T10 T]

(_ I I ! ! I I (~ AC~ ~` { I •'- ~

~ ~{~I ~ i T t ~-_l

:v{ *1IIvu=., VOLL ~ I EM D :?N;, S-TLTS

( I J I ! I I I I I )EYE afR=Iz-TION PEST

_

OT~R l=1 ?ilA~TE VOLLTHE { P

~ ~

~~CIS7

~CK s

1 C/0 S0B C S ~X {

s TOF~ y

m ; n

-~ ~

-77

,. 3

i I `~ •

~ --~ ,-3 Ln

C)

Lo

~

Lo

~~ I ~___ _- =-PIu°

13

J r u 1

v? . '- I I = =_'•`.Y
p. 94

, -

.• STUDY NUMBER STUDY NI7ME

STUDY NUMBER ~t

C)

im ~ i= o o im f m SUBJECT NUMBER

,

T ~ w

CSI SUBJECT NUMBER SUBJECT NUMBER

'•~ o - ~

,cn N

° M=

GROUP NUMBER GROUP NUMBER

--Z GROUP NUMBER

CARD NUMBER CARD NUMBER

CARD NUMBER

L J•J { { {

RECENT FEVER ( I SESSION ORDER

( ( ( { REACTION {

SEVERITY SCORE I RECENT UPPER-INF .I IEXPOSURE CODE

NLJMBER OF r DRUG

J DAY OF WEEK

H

AgTH.*1A ATTACKS O TIME OF DA

Y

{ UPPER R . INF . p ~ FREQ .

t{{ I SUBJECT TYPE

COUGH DRUG

ICOPD CLASS

--~ ~CJ11a T- ' --j SEX

'DRUG AGE

t*ttH:1E

R PUT FREO ,

TI I

SOREIvrSS 1 FREO.

HEEE IGHT (in . )

~~ SORE THROAT DRUG kk-~~f~l

Q, { ^ WEIGHT (lbs .)

SOB

I ~

I NOCT . ORTHOPNE A

1 > 5 CHEST ILL/3Yi: t ~ R:SIDENCE

RUNNY NOS E

rj~

~IC~IO-I~~--~ tHOSP IN PAST 2YR

WHvEZING =1 I W~'--=EZ1-FS AL'SC .t J RESIDENCE L£r

t ~ I I I -_ t ~~ (~I

~ 17 CHEST TIGHTNESS x IMART RATE REST WORK LOCALE

~ ~ ~ ~ ~ t t ~~ •

F__TIGUE I- ~~T RATE ► INDOOR/OUTDOC

~ ~~, £ WRCISE OCCUPATIO N

I I I ( I I I HEAD " tWI

v ~ ?•1INUTF VOLU?~• HSMONGST

1-i~

LI MINUTE VOLUME PACK YEARS

OTHER

E=C I S E

W H E E Z EE

J C/0 SOB C PHYS - X

b.LLFRGY FP,£Q . OF AST,-,T--A

c

)

- r-, 4=• ~ I

r-3 m T 1 ATTACKS NO/YR HISTORY

0

SELF

0Ln ~~~

Ul o y

° ~t ALLERGY

HISTORY F-3

~--- F a-M ILY ,3 ~_j r~ t

cn ;~•~ 1 F-3 t S*10G SENSIT

AIRW_.Y RE SP

I °'iR/IA'TR/~
p

.95 ~

STUDY NUMBER STUDY NIT1.~BgR:

D'w N' J O °

O o o I m m

'o o I;:o ;:o ~~~ SUBJECT NUMBER ( c/1 SUBJECT NUMBER ~

'-i o 0 0

N Cn (./) :m ;o

-a .

GROUP NUMBER GROUP NUMBER ~ GRO

! =1J ~ ~

CARD NUMBER ) CARD NUMBER C~

! o la cn 1~ ~

( I( REACTION RECENT FEVER ~ p

( I I( SEVERITY SCORE I ( RECENT UPPER-INF . E~OSURE ppD

I ( ( NUMBER OF .~-i DRUG I DAY OF WggK

f~~I ( ( ASTHMA ATTACKS TIME OF DAY

I-I-1 I ( 1 UPPER R . INF . 1 FREQ. ?~'

COUGH I DRUG I SUBJECT TYPE

( COPD CLASS

SPtrrUM I ( FR.EQ . I SE X

DRUG AGE

l ~ ~~ SUB. STERNAL El H

~~~ I I HEIGHT (in S ORE NEE S S FREQ ..)

TTT I^

SORE THROAT IDRUG ~

I

I SOB It FREO . ( WEIGHT (lbs . )

ci- I~~~I-` :~ I NOCT. ORTHOPNE A

RUNNY NOSE ~`:l 1>5 CHEST ILL/3YR RESIDENCE

(^yC'(~~ ?(~( (~I ~ rr HOSP IN PAST 2YR

I I~ f~}--- Iti I ~_f WHEEZING W F--- EZE/P 4J.ES AL'SC .I RESIDENCE LENGT :

I I I ~ I CHEST TIGHTNESS HakRT RATE REST WORK LOCAL E

I FATIGUE ?EART RATE 1 INDOOP./OUTDOOR

Q-7-A E=-RCISE OCCUPATION

I 1 I . I I I I I --~ H

:ADACUE H OCCUPATION

MINUTE VOLL?*E SMOKING STATUS

EYE IRRITATION REST

~- I ( I I I I I I OTHER _I MINUTE VOLU*jr- PACK YEARS

E=EtCISE

( ^ r=1 WHEEZE

I° I C/O SOB C PHYS EX

- - - `- - r=,

T -,o o 0 ~ m m-, FR;Q . OF p.STu*1A ALLERGY

~ a

- I ;x c-, - - ~ ~ IATTACKS NO/YR HISTORY

Ln I= i~CC-) CD SELF M

fI

ALLERGY

+= HISTORY

F? *i ILY

1~1

SMOG SENSITIVIT-1

I'I AZ?WtY RESPONSE

"~ ~
p. 96

STUDY NUMBER ►'I ~~ STUDY NUMB:R

V14

~

.

o ~w rv _

T 0 5

!rr+ - - ?, - m m

~o SUBJECT NUMBER I SUBJECT NIJ*iBLR " S cT

UBJ'-L,-

L.n to 0 0 :- m

Ln : c)

~ • GROUP NUMB: R _ f~1 GROUP NUMBER

t t ~ ~ - I J ~

GROUP

L !~ I--~ I I CARD NU-"-B:R c' I CARD NUMBER CARD

la f cn .t, Li ld H

{ f f REACTION K{ RECENT _;V~R 4 ;~-I SL c.

.SION Op,D~

f f ! { SEVERITY SCORE- { ( RECENT UPPRR-INp . ~{ ~OSUP,E COD

( Nf?*SB:R OF '-) DRUG (~I D_Y OF jv~?i; V

( { f f f f AS =11-1k ?T'"~,' CI:S {~! TI_C- OF DT-y

}--l---- IUPPER R . IN F . ~! ( FREQ .

COUGH ~~! J DRUG SUBJECT T:PB

WCf :5 ~ IC CoDD CLASS

i FR:0 . S--- x

10 I ~ I-~~ i~i ~T~ IQ =1 DRUG ACE

I I

I I~ SUB. STERNAL E !

4---i--- t r SORENESS 1.I 1=P.:0.

.~IGHT (in. )

i, SORE =r-,O-!,T

;

:,{ DRU G

T 4 ~=

_ I I I I--_I I SOB 11 I -FREQ . WEIGHT U "D s. )

-4-I(J~IS 1 I NOCT. ORTHOPh:A

RUNNY NOSE I (>> C=- ST II.L/3 1'R { RESIDENCE

HOSP IN PAST 2YR f

! ~-- ! I 1~ 1-- t- I w~-:.z1NG =1 V: _- .,.:/R_As.F..S 5L'SC RESIDENCE LZNC; :

I

; S=DENCI I Iz`~ _ C

I_ I I I ! C= -SP TT _ IG: TI~Z- sS HE `- ?T P,=_T':. P z3T k~ '0 '.K . LOCALE

I I --~{-•I ~ -r-~~-- ~- ,~ ti l

~ f f f f f f' f f~~T_Ivrir. . I E:A3T a7DooR/oU _DooR

OCCUPATION

Hl=" VOLIMIE SMOKING S"'~TLTS {--I { I { I I I~~' zP~._T~ION REST H

{ ♦•-- -t- -r-T-i--i-r t

rE1 I i i i oT~ MINUM VoLU ~ PACK Y: A~ S i 1 j r . . . + '

. ~7 :..L.,.:..-L1rIJ~ - ' • . . ' '

I C/O SOB C f k'~ n P--YS RX

.CB

f

rn

~ " ;~ y r? T

^_1 ~-=1 7--EQ . e T 7 ='RGY

T~ T ' CI S N0 R ATSTORY

I+ O tn [n : n

C .!) --A CD

{ •~ ~I ~ ' ~

h y ti ~' I ~ e? -ERGY

*-3 R--,STORY

=1 = e''I~.Y

~ +-

y~ }s ! ( SMOG S : Z:S~TTj' I-

•

~- ► ~I .TiIa+?i~

~ -

:Y P.:~P0r: s

I

t ~ -----~ , -, ..-,, , t----~
• . 97

- - -~ ~ - - - _

--S 5-5

STUDY NUMBER STUDY NUMBER :t:

ST~}

p

!m

;x o 0 o I m m

;o o ~ ~ = ~~ SUBJECT NUMBER SUBJECT NUMBER SUBJECT

io O O m {

+ •--~ -~ -•~ ( '

N N (n I M

{

GROUP NUMBER GROUP NUMBER GROUP NUMBER

=1v

J I J ( 1 CARD NUMBER CARD NUMBER CARD NUMBER

1= la cn I -t, Lo

{ {{{( ( REACTION I{RECENT FEVER SESSION ORDER

-I--{ I{ { {{ SEVERITY SCORE RECENT UPPER-INF . EXPOSURE CODE

{ { NUMBER OF DRUG Jk,~SI DAY OF WEEK

{ { { ASTHMA ATTACKS TIME OF DAY

F-- 4-1 1 UPPER R . INF . kI FREQ . {

COUGH DRUG SUBJECT TYPE

COPD CLASS

SPUTUM FREQ . I SE X

I 1~ DRUG

I I I I I ~ ~ ~ 1 SUB . STERNAL ~ H

AGE

}--}--~ SORENESS itl FREQ . HEIGHT (in.)

{ 1

05

~~ SORE THROAT ~ DRUG

T-=t--lO~l-a

L~_~J~---}---- I

ISOB I FREO . WEIGHT (Ibs . )

{ ~-- {- r I NOCT . ORTHOPNEA ~

~I --1 -I `}~J RUNNY NOSE 1>j CHEST ILL/3Y'tt J RESIDENCE

I {~I--VV~ICjI I I r 1HOSP IN PAST 2YR ~

I I~ I 1=1 _I ~jf WHELZ'NG =1 1 WE~:r EZE/R4LES AL'SC . .I RE SIDENCE LEN„T'--:

( I I, I~ CHEST TIGHTNESS N."EART RATE REST WORK LOCALE

J~---~----I ~t~~O\ I- •

FATIGUE :r'.ART RATE I INDOOP./OUTDOOR

-~`~ GOIOI~ I~ p . j I EX✓RCISE OCCUPATION

I I I I I I I HEADAC HE lvl I --- H

MINUTE VOLL? F-E- SMOKING STATUS

I_~J EYE IRRITATION REST

~ !

I ~ I~ I I I OTHER =1 MINUTE VOLUME PACK YEARS

~ EXERCISE

1 WHEEZE

n W N~ lo .-~ o ~ I C/O SOB C PHYS E X

n =c --- i` z= m I FREQ . OF AST~A ALLERGY

o o t

>

m

< T T I ATTACKS NO/YR HISTORY

o

cn a t ~ "77

SELF

-~ ^ -< •-,

-3 0Ln V)~i CD loi~ m o xl

ALLERGY

HISTORY

FAMILY

1~1

+~I SMOG SE.ASITIVZT:

I~I AIRWAY RESPONSE
p. 98

STUDY NUMBER STUDY h'I1"IBSR ---

~ •' ~~~

~

iw rvl_ 2 2

1-<

T

~

t ~'f W f'n c? m

C) ~ ={ SUE.7LCT NUMBER S

o --1 7- 70

44-- I

o om ~0

N l/) Ln ! G

7

• --i ---i -i i ~'' ?' ~4.

~ J I • ~ GROUP NU*SBFR GROUP NUMBER GROUp

~, ~

C_9RD NU*1BRR i~l cf~.Rn NU*ibLR

la

..R

~ I o (~ . I n~ cARD NU*IB=

I RZACTION kl I RrCSi\'T -.EVER

~-- ( f f f ! f ! SEV ,rR J I S£SSIN _R ERITY SCORB ~ f I RECENT UPPBF.-INF

. rOP.Dr

I I N

I F~..OSUR.. CODE -" i-HSR Or DRU;,

I I ASTH.*ia ATiACI.S ~~! IDAY OF k~~x

I I I I UPPER R. T

^ f T ~ OF D:Y

i I I I COUCH I~r~ kl I D

rPHO

P.UG I SUBrCT 'I'~-DF

f- -~- ( ~AS I I I I I I~~ ~~ ~ ( COPDC SPUTUM S

I '~ o' I SsX

- I C ; DRUG 9~~

1

. ST:RIZ4L 1 ~ SUB ,

I i-f---~-~-~-~I ~ -- ~- SoP.Sh~ss 2t) I FR:o .

I I~~ I I I I~_ I L,s SOP.; TUP Or,T DP,U f

ii:

IGHT ( i~ . )

{ G

1 I I I I I i-- ( I SoB

Ez--:

~ -r-RE o .

P~ T,rIGHT 1-i 1<-> I

f

--~ ~ I NOCT. ORTHODh~~, 1 ~~ I f I I 1~

F

fw RUNNY NOSE __i_

-

I~I ` I ;I >> CI,= ST ILL/3I"8 ! RESIDENCE

I_ I I 1 _ ~^ f I HOSP IN PAST ZYR

I I I t- I I wH.. HZIN; f FULL?'S 4USC .1 P.= SIDLNCS L3N;,TH

i I

~ -f---}-{ - -- ? ~) I I I I I I I I~ C: _sT TzCHrrES . 4t?, P.::ST ~ w'OP.F. LOCnL

L I I I I I 1• a I T~ !

~-~ !O _ I I r~00R g _ _1vLz r.i T P~T_B

I_ i I I I I I I I I --~~~C=- ~I I RCT_S: 1 OCCU-?-A-7 O N

iYB s' .P,IT ~ - - - -

:TION ~ I *1IlrZTTC VOLL~ S?~Oti1t.; S_~TL'S

~I PaST ~-)

OT=

*SINlJT; VOLU ~ a_n..

~L Y:.aS

I c/0 SOB C PH-Y S

ST?~~

.

.X ! eTT =R~ ?

~

1 LTTAsND/YR

OF

rT- STORY

TSELF

y

a LL ?P•GY

£~S_QaY

~*i~.Y

H ~

S*10v SF,t;S?TTVI^'Y

!=1 ,~

j CL_i;! 1 IL.L
.L~

., _ .

C)J STUDY NUMBER STUDY

_ -~ -,, ~

NUMBER (~J STUDY N~~•

..

o Iw rv -'o o

~R o 0 im r--) m

~ ic c c x n~ SUBJECT NUMBER ~ SUBJECT NUMBER SUBJECT I~g"'°

io o i o ~

co

ICJf -i fl ~ _

~

t~ (n IM ~

--I GROUP NUMBER GROUP NUMBER GROUP NUMBER

CARD NUMBER CARD NUMBER CARD NUMBER

1 1~ o .o ~ Ia c', ~,~

REACTION RECENT FEVER -~SESSION ORDER

~ SEVERITY SCORE RECENT UPPER-INF. E}:POSURE CODE

NUMBER OF DRUG (-TN DAY 0F WEEK

K-D ASTHMAATTACKS z 777TIME OF DAY

-- ~_ UPPER R. INF . FREQ.

COUGH DRUG SUBJECT TYPE

COPD CLASS

SPUTUM "I FREQ . SEX

DRUG AGE

SUB . STERNAL

-1-_ I --4 - i- -i= ~-i SORENESS I FREO . 1(7~~ HEIGHT (in .)

SORE THROAT DRUG

T75 fSOB

FREQ . WEIGHT (lbs .)

Z:l I NOCT . ORTHOPNEA

RUNNY NOSE ENCE > 5 CHEST ILL/3YP. P,ESID

~ HOSP IN PAST 2YR ~

1 WHEEZING WHEEZE/RgI.ES AUSC . 1 RESIDENCE LENGTE

t j

-) CHEST TIGHTNESS ~ HEART RATE REST WORK LOCALE

aI

~+-d

FATIGUE . ~~ HEART RATE INDOOR/ OUTDOOR

L J~Or\<tz,:5T:51 EXERCISE OCCUPATION

I I I I HEADACHE

- I MINUTE VOLU.*FE SMOKING STATUS

EYE IRRITATION RE S T

I~

OTHER MINUTE VOLUME PACK YEARS

EXERCISE

I I~ I I '~~ ~ I WHEEZE

iO ° I C/0 SOB C PHYS EX m`

o~

C::> !m

m mT ALLERG FREQ . OF ASTHMA Y

~ o

c = :x = ~-I ATTACKS NO/YR HISTORY

ccn -N-~ ~ --Z) I -7) SELF

- ~ o o I Ln V) LnCD Im o

f i ;z

ALLERG'Y

HISTORY

FAMILY

SMOG S'fiSITIVITY ;

IAIpw!-.y RESPONSE

'~I i
~ ~ -F~ -~. ~- •~~~°'~.:„

.

STUDY NUMBER ►~f-~ STUDY NUMBER 4- STUDy

t :m j •_ = • • .

:m o' tm m m

-0 1= UEJI.'CT NU*1B:R I SUBJECT NUMBER ~ SUBJECT NUMB-_zZ

D

io o o m ~

~ I . i N N (/) G7

~ t -J GROUP NUMBER GROUP NUMBE ! ~1 GROUPR NUMBE

R --------------- CAR D NUH B E R CARD NUMBER CARD NUVBIR

o L~ la cn 4, ~ ~

~_ ( PWACTION ~I N 1 R: CPNT

~-1 SEVrRITY

r'LVrR \I SESSION OP.D=R SCORE I ! RECENT UPa-

'

=_

- NUMBER OF I~' U-~OSUP u

.E CODD

~_~-j! ( ( ( ( ( AST-r'V-A ATTACKS

DRUG DAY OF WEEK

TIME OF DAY.

I~--F- I I UPPER R. Ilvr . G.I I r .=O .

-

~(

-

4--- COUGH DRUG I SIIETCT TYPE

I COPD CIASS

sPUrUrt

I C)IO I I I

IiQ~ I O =1 DRUG • ACE

~ I i~- ~ ! I ~ ~ I ( SUB. ST:R2Z4I. ", H

SORENESS EI Z=o . ! "L c -) .rI~,~T in

I f ( I I I I I h~ SORE T=_:,.'.OAT DRUG 1

SOB I r-`'tWO, k'~Iv^5T (1b5 . ~ I iGl~l01 I'~~~I O l~~v .~1 I NoCT. oRTRODr;A

RUNNY NOSE ) (>> C==ST ILL/312. P..:;SZDLNCI "

:71 1 HOS? IN PA ST 2YR

1 W~.?Z=/RtI.IS ALSC .! ?=S DSNCD LEN C-77

i~•~-~f~ I~I~ 1C1 {~1 ~-1

~ I I I 1 ~ ( Cr- I.ST TIG3T2aSS =`.?.T P:TZ REST w'OP,F. LO ~-

I T RAT:

I 1NDooR / o U _DOOR

I

I •~! RC?SE, ~ OCCL?t_ION

_

-- C ! MINUTE VOLUME- ~ S?•ioR! ~r;, S"''T'LTS

REST

I I I I I I OTHER M IN=." VoLtrv--.

pACx F=.AP.s

:~~CISR - -

pi V~DCS

t=I !C/o SOB C Pas

y In ~ 1 ~.:'~ . 0 P e~"'z .?.re °7

7 ~ ~ H t;•~ T ~ _ '"i'=R u

~ -i O SELF

NO /?R EISTO?3

~ N C:)

~ o f

I -• O~ ~ I I N

H H +~ I ~ eT

. I

~

~' I _

..'L: . y

r--lj R-STOaYJ

H ~ . ~...

Ln . I

i____J ~ T~~r ~ P`S~or:S3 I

'~~ I I