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SPUTUM J L SUBSTERNAL SORENES S SS 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 ~ 1 1 r RO N T?_L : NO Y ES 

# i
E' :E I R RI"'sT 7 0N 

# E- i-) ) OTHER SYyDTOM S (LIST) = sYmo toms & disccrn_o ; .t =s z ed several hours , • ~- .~ - 3 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 m a ximum amount of v o :'{ that you could normally

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your J r ~_ 3 2s`~i ?i i' 1 SCORE SHEET -/n p 5 

## G~uP , • , S 

### U BJECT NO . 

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~ DATE / Fz~e

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AL SORENES S OR AI~IA~ESS 

### 3= Moderate SOR .i = AT 

### 4t0'S (or HOARS LVSS ) Sorr ,--,„-hat 

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### GROUP SY 2~P iL I ? SCOPE S'r = T p 1 6 

# lbSUBJECT 

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~- would they cause you t o
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### H . V L~i _ an =e_r-en ._ r rscm

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### SUBJECT T

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, A . Decrease ootior- al or recreational activity List B . Take additional medication C . Be unable to pre f or m 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 unab le 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=.=

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# ~-- 

# r. GROUP SUBJECT NO . /06' 0

CORD . c f- ~ ~ra c z cn m cn x SCORT :ZG a. 1= :ON- 20=
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.S 

## F JmUt'1 / SUSST°3^t4L SORENES S OR A V aR E .tES3 SORE 'i H RO A `i

S- COR".'^fE So OF SR E A VAS :__ ~_SC :•-'_?G?,~ ~ ~ ~~ ~~ ~ 

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GROU P SUBJECT NO . .

_ DATE o w ~ :a F w

~ ; L C7 z z COND . rs , F- . SCORING a rs z m co c o 1=NONE 20="fODER4TE Cf) C- ) x o .- : C-~ E- E c 5=TRACE 30=SEVERE w c . c G ; F ~ E m co w r Cn o w co rr F 10=MILD 4 O=INCAP . W X H x w x w x ~ w c>~ w cc w w rz a4 pa a,o COUG H SPUTUM ` 1 ~ I 1 1 / I I SUBSTERNAL SORENES S OR AWARENESS 1 t J / / ` SO^E, THROA T (or HOARSENESS) I Yh Q 1 ( SHORTNESS OF BREAT H NASAL DISCEA?' ;~L % CONGESTION 1 ' 

# T i

✓ , WHEEZING 

## 1 1 ~ ( CHEST TIGHT, : -- C / RESTpiCTION f-j FATIGU E HEADACHE ` FRONTAL : NO YE S
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

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. - - COUG H 3 PUTU M


# _ _ _ ~u3sTlaN1i . SORENESS OR AWARENES S 

# y~ri~or~S^ ~ zsS 

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- T_ ` = ._L O ll 7 _~- E ;? S71f P ^ 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 perfor m 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
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, 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 . - De :Iot' m - Tura t h is v or' 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



## GROU P SUB j ECT NO
. 

# 106 1 • 

# ~ DATE ~ E• C z r, ~ COND . cc H 'H- ,~ z 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 

# 1 (

1t~ h l SUBSTERNAL SORENESS OR AWARENES S SORE THROAT ( or : :v A DSi . : : .t ' .SS ) SHORTNESS OF BREACH 

# . ~II NAS A - 7, DISCi' .=GE % CONGEST=ON • WHEEZING I ~ l CHEST TIGH"'"7 7 SS ~ RESTRICTION
: ? .TTGJF HEADACH E FRONT?

.L : 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 : :al medicatio n U . C . Be unable to per=o= the maximum amount of work that you could nornallY perfor m D . Turn t- s wc-' .-.ioa- L_•re_ cic . :nld :s _ea- . : :sz _Ese ) Sc a'-- I or _- -2_ C ( c c c a-- I , S c c- c--~ ._ . .-C_
.

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

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# U G

# i3 ~5I PUTU M J3ST E °NAL SO R ENES S R A W ARENESS l ► I ~ f ~ l ~ / ~ ORE THROA T or HOARSENESS ) ~ I I I =ORTNESS OF BREATH 

## ( 

# j ?SAL DISCRSRGE / ) NG E STION f
c + LZiN G _EST TIGHTNESS/ STR_CTIOi1 

## ! ~ ~l

r 7 LrU" . . ~ • I I J ~/ ~ ~ 

# I l

' LACII

-- i i I ( j r .Oi1TAL : NO Y ; S -~ 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 ) SHORTNESS

OF BREAT H :1ASr_L DISCHARGE / CONGESTION J J / ~ ~ WHEEZING 

# I ~ l I III C : :EST T=GdTNESS / RESTRICTIO N 

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# b 3 . Talk-` ac ~J ` cn ,= ?. Be ts :._ble to prerorm t_ n e mGcri-m = ctmt of work t : n .at ycu could r

.oz mal ? 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' .4 l wark ac tivit.T or 

### level of procict i v? ty ( ccz-.m ati cr ., 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 

# ~.,~E CT 

### J 

# .1

LOZ 

## S D?_ ._'r""' .a - 7 ._-, r r Bor g ~ ~ E :~er- .QP 

### COND . O .Z ^ N c''1 Sc =- .c . -1-MI CC!l ~ F ~ ` 1 ' `'' ~ t r~ ~ 0=~7otzin1 

### 5=?"Z- 

## CE Cr) Cl) 

### c 

## CJ a t ^~v cn 

### t=- F- iJ15= : e 0 COM-1 

# _ ~~ ~ 1 ~ ~~~ ► ~~~~~~~r ~~~ •~ ~ ~~ ~ ~. i S~u~ 

# V

~ 1 

## ~t 

# 12= L 

## ig; , t C'c

-



# _ ( ~ 

# __ L 

# V ~ C7

NT = 7

_ --- 10 i 9/~ 

### l illJ, ~-rC-~ z i : FS "C==C~ : ~ ~ ~ •

. 1

-- 

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

I= & as~~ s2v~a? hot~ . 

## 7 w~

### uld t hey c :--ii e yc,- to /rtr/ A . De ,-e_z- s2 optiona or rec r e=t ior .al ac -~jvitv Lis t 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 w 

## or_tLcad 

## level aa w'- ~ reQazd fati 

## g .ie ) 

### E . Be tmaDle to Perform Your usual work activity or 1e

- .re1 of productivity * oc" mat_on, sc=:colwo r'_c, 'house!--old aut ;es ) 

## St: ---v at hcme sic : (Icsz si 

## (: ~c 

### from u

## ,-c r'_c) Visit vc 

## ur Fn,TSic -' ~ n i - V i s i .t an e T'°,-? e r c : - r^cTl~ . . .~ ~ q . 42
!~ ! l !
" Borz

~D EM~~, c n 

### C Q M . r 4 c") }-Z- 1 L~'_ r~' scale p ? , ~! ! r= ► - ~ '- x t{,¢ ~ ~%' cn cn CO r F= r F-- N F-= cr) ~ t{ 0-3\7 0 NGD,r . 20"~SDE ^ "-- c .~ c~ 

## , , 

## 1! L`~=r~ 

## _~ E" E~

L~ E~ ~ v] cn crl C i{ ~ tr} v7 --'~ n f- •- .' C=- -~- 3 Q ~ .~r

. .'I~~ % ~ t ~ P
. U] 

### T Q_, ~- r =D Q 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 ~ ~ ~ ~ / (

' f , 

# 33-=~ = l I ~~ j : I



# ~ I i l r ~ == _-_-__=- / I I • % ( / / ~ / I ~ I

-

__ -~_-- i• , ~
.



# 0 1 3 16 

# 6' 1 S

# =C- 5 cL C__~,
. 

# = vrr' ~ --«Si
. a S Saver- +

- N-ould they cause you to

. -/ . opt :-cr . I- or re~-~ea tic r.al activity Lis t 3 . Take additional rrp-i -T cat --on
~ . Be un ab le 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'~ Sl c' .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 S

### CO L 

### -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' 0 0 

### .= w~ a cz w w 10z = 40=INCAP . ; 0 . S=Very, Very ' . Littl e COUGH 0 

# 1 10 0 R), ' 1= Ve ry light 

# sPU M 

# ,~ J LL 

# / 2- 

# - Light SUBS TER•jAL SORENES S OR AIq ARII NESS ~ J ~ (l Lj 

### i /1 

# LO 3= s bderate SORi ~AT 

### ( ~ (or HOARSII~IESS ) I ~ I 4 to Soa•e ahat f / Heavy SHORTNESS OF BRFAIH 

# ~ / ~ ► 

# H 6= ve2Vy NP -SA L DISCHARGE/ CONGESTION '/0 7 to 9



# 0 l 

# 1 Very Heavy 

# :~-H~~~ ! D I I I 10I 

# zI 

# r~ WD ~~ , Ver ~ 10= Ver~y, y 

# L -HES T ST TIC~-IZIIESS / STRICTION 

### 1/0 He a 

### A

# TT~~~ i~l 11 I ~ ~ ll~ 0 

# l r ;!I 1 1 ---R0N~ '~rT : -N0 YES
S ) 2, aDN S 

### (

# LIST)
30

# RC =R

# TZO N SCALE 

# (o-lo) ~ ~

. 0A 1 T Cf symptoms c~ discomfor t 

### Lasted several ho ur s , ,l ould 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 physicia n Visit 

### an e?-!



### -e rbeP .cy room

# J 

# 1p ~ J ( :OUP 

## 02 

## ~7 I + + TJBJECT NO . Borg E+ C' i ~'s C7 C7 

### Ec E'-rtion p

### ND . r+ cu c

### n Scale 

### CORING W ~-i r-4 H (14 ► -+ c n O=Vo thin~ =~yDNE 20=`3~DER AZ E ~ o Q



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

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

- OU("~I 

# 6 1 v 

# 1 loI lVl 101/0 ( v Little I I ~~ I Ve ry lig h t PUM 2= Light UBS =9 IIAL SO + ~ +

RE`IESS R A '~~~5 3= I -t derate 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 D2 C= 

### ~O

# N TIAL 

# : NU YE E -TLTION 15 1 52 I i 

# I S 

# T ) J RG E =

ON 

# 3 :ALE (0-10) o o 

# JOc) '

--------- 1"7 0 6 . = syurotoms & discomfor t a ted several hour s , ;uld they cause you to -~ + ► ~ i Decrease optional or recreational activity Lis t 

### Take additional me dication Be unable to preform the ma xLrrn,m amLmt of work that you could normally perform Turn this wo rkload level ow E~isre~ard fatigue) Be unable to perform your usual work activity or level of productivity ('` occupation, schoolwork, c ri tical house hold duties ) Stay at home sick (lose sick time from work) Visit your physician , Vis i~ an eme_,-oen cy roomGROUP p i~ 45 SUBJECT M . DATE Borg E Yertion COND . .-+ c 14 c n Scale SCOR~IC' ° CL x 

### 1=11~r

_ 

### 2o=~JDERAT~ Z 

### ~ U 

### , ~ " u Cr) O=~~TO thing 5=TRACE 30=Sc~IF~E "' M i " ', . c at all w a. cn 10= M_= 40= !NCAP
. 0 . S=Very, Ve_•-y Little MUM 

# 1 D I 3PR 6~ l= very li , .41 t

, IJBS =R I'~AT SOR = SS i I,i g~ 1t )R 3= ~b derate :OR~ i~~DAT ' 4 to ' 5 or M
. . = S) 

# 1 ~ S Heavy >riORE~ESS OF BR

E ~ Z / 1 6= H~ 

### ?Sa_ T 

### , D 1 : ES Q

### 7op. E -

-- 

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

# NG ST 'I=-i_TI Ei SS/ I3 10= Very, Very :, :ES T 'ES T. _1 C~'?ON 

# 1)0 D I



# 1 0 1b 2 0' Heavy



# -' l A

# _~~

^

## ~ ' v 1 I '/ I 

# lo 1 I~ 1C~~101~ {~, Iy l ~
;~'cG ~ ~~T?'ON ' ~ t 

# ( 0_1

# o

# ) 1 r7 0 

# v v lo ' o l 

# 0 1 symntoms & 

### discomfor t asted several hours , -o uld they cause 

## you to ~ -- -- , , ,---- -- _ .. . Decrease optional or recreational activity Lis t . Take additional medicatio n Be unable to preform the ma xinum amount of w ork that you could normally perform • T~Irn this workload level ZEivn (3isre
- ard fati g ue ) : . Be unable to perform your usual work activity or level of productivity ('` occupation, s c hool work, critical -household duties ) Stay at home sick ( lose sick ti 7 e fr u ,70, rk) Visit your physic ian Visit an c-mer ~encv roomp . 46 Mo

# u- p 

# o2'I/ ► , , SUBJECT N0 . 

# +++ 

# -~ { Borg DATE ~ ~ Zi t 2 CON D . rr 04 Cr) + t+[J j~4 S C-- ° SCORLVG r-r c== w w w r-= cv r= w+~ ~i' Cf] Cn M 

### O= 

# - Tot1 

# ti_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 , 4

e ,- ;, ,Q✓ ~.sr . ~ 40==VCAP . 1= V

# e m7 

# ~~t -61 51 

# 2= L i,= t, BS 7 -r-iT•_Ar 3


# _ L to -3 = o r .-~_-



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

# .

~~ 06-1 7 to 

### v .
101 /1, v( `' ► ~/ l I ~4i 11~1 a= vv, :vv , E _= .. , (Z T '-C-


## ~ T R I 

## c~oV 

# ~-~ ► 1~ ~~ ~f l~~ ~~ ~~ ;

I 

## _c=~--~ O 

## ti = , 

# 4- 5 L::. 

# 1( a-

_ 

# ~ o ) 

# 0 

# v ~v0{ {~Iy = ' = syarotcros & disc =f ort =5 te :J. several hours, ~- f ✓ ~ v/ ~ ✓ / • ~i /

--uld the, r caus e you to

, ,-+~ -' Decrease optional or recreational activity List Take additional s:ed_i . .catio n Be 1m -a b1e to preform the m a. .dna m emotm .t of work that you could norma lly perform R= this work-load level down ( di .sre g ard fatigue ) Be unable to pe_T-form your usual- w ~ rk activity or leve? of productivity occ ,=ation, schoolwork, cr 4.tical household duties ) Stay at 

### home sic'_ ( lose sick t 7-e from work) > ~~~ Vis i t your physicia n Vi, ;4t- an em

`roenc,r roam 

# 7,~ ~ C~~ ~ .p . 47
G '-~CU P 

### SU a TE.r .T m . ~'~

~

j Bcr-_- D°T" 7 ~ ~/-t~ 

## w F=~ ~ C7ctt ^ 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 c ri t t U ~J E~ d=~0 Ci1? T= UN


## _ a n 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

# _~{~_ ~ j ~ t<< I



# l 1

~- .-- ._ - 

# . A 

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

### -=- c 

# = N
7


# _ - 7

# _~ :

- - . ~ -_

cx 

# ~~~ ~~ 1 ► ~ 1 I 1 _~- 77,

# ~_~~`

au S2Ve'_" al 17 Ot=3 , ~~u1d they cause you,' t o
-•~ror s- .. `, ;7~ I ~ -~ - . Decr~s2 ootion p-l or recreati or .a l ac ----,L

vit -,7 List _ _ Take ac ~ tional u-edic.at ;on _- Be unable to praform the Tax~ m-cunt of w-or i c that you could normp-11 .17 Perform 11 = -, t_Szis wor :ctoa d level down ( aisr_ gsrd fat
-- ;g!-l e ) Be unaDie to perform yo= usual work ac tivi . t- T or level of FroaLCtivity ocz* .m at=on, sc.colc.,-o r :c, c~ t=~ hcus einold du .t
-- es ) r'_c) ~'~-•~~ S t` ~r a t hcm

.e s=c'_c (lose sick ~~ ~rcm F o V=Sit an ~a'?°nC :T CC l ✓ '~~~ ~ ~ L 1 ~ \~ -_ ~ Lp . 48. S~r 1~y1 SCORE SrtEET 

# 30 ~,' ~ l . C ROU P 

### S'JBJECT i~ .~ ~ DATE 

## 5/7 Borg

, .7 ~ Exe rtion CON D . R= ~ c7 i 

### Scale SCORING P 

### 1-1-1 i 1 i P4 v' ; ~'~ F--4 N ~ " ' 1=~NE 20 tiSJDERATE ~ O=~T o ~ ~ m o , In En at all R! o 0 5=TRACE 30=SEVEftE W 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 A W AF q= 

### 3= Moderate SORT THRO AT 4 to : 5 = (or HOAR..SE~ '~SS) ~ + f I ~ ~ ~ I~~~ ~ t Sca~v~a t I l ( Heavy SHORTNESS OF BREATH 

# 6= : :e a

# vy NPc~Z . DISCHARGE/ i CONGE rSTION 7 to °_ W= LNG Very heav y 

# ' i I ^ J I I , a= T TIG~iT~~SS/ 10= V er,Ver . RESTRICTION Ieavy
~ ~ I I F FATIGUE Hr `_ : 

### Y

-11, s -T~TIO N 0IKER SYNF`IbNS k (LIST ) BO RG = 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 m edicatio n 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~~ rccmp . 49 

# -51 ~L

### SCORE SHEET GROUP SUBJECZ 1

\0 Borg DATE Exertion CON D

. ° Scale w w w Hif ~ 1CiWG 20=` 3JDERATE 1 :14 C al v U) w0=Nothin g Cl) cn a cH n o i w c~» M at al l 

### 5=TRACE 30=SF V~t~~ o 0 w a l0=> .'~ 40=INCAP . 0 .5=Very,Ver . Little COUGH Very light SPUT[JM } 

### 2= Light SUBSTERI AL SORE'iES S OR A R AK"~ '~SS 3= Yo derate , 1 I 

### SOREE 'I ER UAT 4 to , 5 = Som~ahat (or HOARSENESS) 

# 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 & discomfor t lasted several hours, - -- -- • would they cause you t o r y 1~~

_ 

### 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_cia n H . Visit an errerce n c y roorip . 50 SYl` IP'"i 0M

. SCORE SHEET 

### GROUP SUBJECT N0 . Borg DATE Z/ Exertion COND . N M Scale Q! r-- I 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 . 0 .5Very,Very 

### 4 Littl e

( I i ' f CO

### UGH 

# S 1= Very 

### light 

# ~ ~~ f~ 1+( I ( ;~ 2= Light SUBSTER.I AL SORENES S OR A 14 

### AF U 

### IESS 3= Mo 

### derate ! , , SORE THROAT 4 to ~S = (or HOARSENESS) somew=nzt SHORTNESS OF BRFA'LN Heavy



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

### NASAL DISCHARGE / CONGESTION 7 to 9 = Very Heavy 10= Very, Ver

. = ST TI Q TT TNE SS/ Heavy RESTRICTIO N LCUE ADn = I Tr ; H E 71~ NTAI : U YES EYE . IRRITATION 0'L 1'_FR SY = NS (LIST) BORG EXmTION 

### SCA.Z .E (0-10) 0 o If symDtoms & discomfort 

# 4 las ted several hours , "70 

### uld they cause you to 

# ID

k . Decrease optional or recreational activity List B . Take additional redication Be unable to preform the TnaX im an amount of work that you could normally perform ue) D . Tlzrn this workload level wT disregard fati g ork activity or level of productivitv E . Be unabTe- to perform your usual work'- (- occupation, schoolwork, critical household duties) Stay at home sick, ( lose sick tir_ p- from work ) Visit ycur physic an l ~~ Visit = e_rer 2 e n cv rocmp .51 

### GROUP 

# , , . S'LiB .JECr No . _Z01

6 DATE , Borg F :ae_r `-`.ion COND . 

## E5 K N Cn Scale

~~ 

### RLNG W 

### w C!] 

### ( ] 

### M '~' ► ~ . . .,~ _ 

# z= 11ME 

# 20

# =

v_D 

# D~ = f :~ r--i H M 

# 0=va t 

# , ; ~ E H Z H E- + c ~ cn rn cn O, 1 t : cn cn at all 5=TRACE 30=5 F.V~ '~E o Cn 

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

# itLH_LL±ULLLLiveryijgt

~~~ 

# 1~ ~ ~ > > > 2

# = Light SuBSLI•laT SOFE! r ~S , ~ 

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

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

### H ~

### _F _I=qS ) 

# 5-1 Sa t 

# _~rT T TH0~'' ME SS OF BRE`=I- ; I' I I 1, -e'"`V Y 

# i 6= H

# za-V7

# y ,nNC_FI777 

### OV 7 to 9 V e=,7 H°

~-=vy 110= Very, Very T T=C :ii~SS/ Feav y 'c! T= _ON I _,,--

-- ~

. .-. - --- -

- - . . 

# ~_>
7C

# v IORG 

# (o-lo> ~~ ( I I symp tcr o as ted sev se& di s ccmfor `

ral hc= s, ould t:~ey caus=e yeu to 11, I --~ ~,- I 1 1 t . Decrease optional or recreational activity List Take additional rnedicatio n 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 ~` . . ;^ ;`cp . 52

~ L `, ;~ v ; r ; ,t • 5, ~; . 

### 5-,: .,, . C

# H SC :'i . u

: . r_- .~- .. 

# 1 

# GROUP i t t 

# s- 

# U-&Mc

# -L m .~ 6 t t 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 ° c= t5 c~ c~ t t SCORING ~r 2' cn cn cn xtit I.=MrIE 2U-`JDE~r . • c--' ~ r~ r ra cv ,- ; c n ~""' C!"'J C . :[ C] U .1 .7 O=~~t L~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=JEr y 

# , ve~ :7 

# 1a=~, ~=~1~p, ~~tt LitLl e CO

# ~~ 1= ve~ " 

# z u 

# Q " 

# S PTJ=

. 

# ~I !+!~ I I I 1 I i I ~ ;_~;1 f 2= Light t t 0 IR

!II (c


# _ Srt . 'tL : S OF K'-~-= 10 1 

# C C 

# ~~ C'~\ 1-1 

# C~ i~ ~ l~ 1 b~ ;?~~ I { ; t o 9 V

## c,-, 

# _ : 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~ 1 1 l a s `ed se~ er~ hcL s ~ ~- t t t w o uld t

he T cause_ vcu to 1 I' t t ~ A 4 A . Decrease optior~l or recreational activit-, 7 List B . T ake addit~onG_ ~~dication C . Be un able to pr`= or .-z the =c tmt of work t ha t you could no r :q---11,7 perform D . T= this workload level aow~ (aisrevsrd fati Cr l e ) E . B e unable to FE : :-f orn your usual w c rl& activity or level of productivity (` oc =a tion, sc '-.colw orkl , cr -i ticsl household c ~, ties ) F . St2y at : home s=-- k' (lose sic'-, t ; -.e from work) G . v = H
. S-- rccmp . 5 3 $' L~T= C:~r SCORE L. 

## G O

## uP 13-J16 

### S' L

### 1BJECi M Borg DA= 

### ' i CO ND . SC .`le SCOR D IG N,~ 2 cn tn cn >c r r ¢ h -i cV F

- c'7 L- : I ~J ✓ 7 rL = 

### 1=1 ZNE 

### 2J='~JDEZ

### ?_'' 

# U Q , tI 

### , ~ ~• C~ cn cF! C - . Cl) Cl ) C 1 i C H i'_ + c.~ 

### 5= LR 

### ^-_Ci 30=S -E7

### 1B~'- %F R c- : c= : c c :2.1 a P-1 P- C

n 0 .5=Ve'`" % Lit 7- ' 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 c r OR _^- S I + ` 

# 1 ( ~ , r = ~ c_--==

SCrL :1HF n A

r (C r 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~~Z 6

~--- , -- - - -- - , , Ir It I l ,
sy =- c=L,,s c~ 

### discomfor t L :QLTrs , ould they ca-use you t o

. 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~ .~at ien, schoolwork, cr~t_cal household dut~es ) S Lav at hc= ( lose sic'-{ t:f1-~ from u ,Cr'_ :) V_._~ roomp . 54 1~ MOL P 

### SU BJECT DID . , I DAM 

### Borv~ 

## corD . I E~~e_ CP_ .~ C14 ~ Sc`l e SCORLTG ° ,✓ ~ cn < 1=NONE 20-`~D' .^-"~ P- cir E- L ; r--; ► ~ `n ~ ~ ~ F ~~ O=\7CLtiin ~

F E" Zi' ~ N ~ ~ ~ ' 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 r SS L~Jl 

# 2_
Lt OR I11 ~ ATv~iCr11h

. . . S, I ~ I 1 1 to I I~ ~ i- ~ VL~ r . : OF B= . =__ I I I, / ~ ` 

# i~U il o 

# j/ j j ~!~-~ c= 

## c=- E

## ti=--- 7

# c= VE : :- 

# - RES

## tc _c~

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# --~~ 11 

# ~~



# _ I D L : s = Lcam

s c~ d=sc 11 or~ I, I I~s ted s evC rG1 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_ medicatio n C . Be unable to preform th e ma. -c n m unt of work tha t you could nor_-Ti,lly perform D . T~mm this workload le vel a cw-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 c r : ,~) G
. v=si .t Vcur Di . -- ? r
~ - v ~S L'
. ~, - "' ."p . 5 5 /L• ~'~ !l,~_ ~~,~ . ~ Jt-_-__ ._ J ~ ~~ C~ "~ ~~ S ✓ ~ 

## ~~- 

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# r s U 

# BC ~ Borg DATE E : m rt 10L1 

# co N 

### ID . J ~ ~ N C11 Scale SCORING C/I c1] Cr )p-+ r4 c N ,--+ m W~ ~J ~7 T i~i n o 

### 1=~I~1E 20 ~3JDERAT E 9 . 

### 0=0 t ~ E-+ E-+ Z, i E- E- ca E cn C n 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 c n 

### 10=~7 40= IN



### CAP . 0 . 5=V 

### ery 

### , Very Litt1~ C

# nurld 

### 11= Ver

### y li g

### ht 

# SPUTUM 

### 2= Licht SZ J~BST~~?• .,A7 SO : S :)R A?vA_ TE~IFFSS 3= `tderate SORi Zr~L2T y ; 4 to 5 Heavy 7H ORr`SS OF ~

BRF~T'H ! ~J 'i~~ ~~ ~~ '~~ 1 ; ~ ~ ✓ i ~ U= D, Clj I a F ~/ .` 1 I ~ , . f % to 9 er•J H e~~ 

# ~ _0= Very, 1e ; 

# l~~ I %I .rST TTC :~i .ES S / _~~ , •~ ; , .~i,~ ,~J~ I

~- -~_~ .-~_

S?`=i~'S 7_ .~71)

, 

## L ! + } t 

# , 7 

# i (0-10) 

# ~

T s = tcros & discomfor t - =-sted several ho=s , -,Duld they cause you to -o r _ , !1! Decrease optional or recreational activitv Lis t Ta_ke additional medicatio n 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 physicia n Vls~t an e er~e~cv romp . 56

SU

# E

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.

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~ C7 i CL~ Z 2 Exc= _-4 cn z t t Cam
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- + ~' z, t ~-« E ..:

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

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### LT sy~tcros &~sc ~nforr t t I 1as ted several hctiss, t t , w o uld they c aus e you to 1 ~ httt ( r --' A . Decrease optional or recreationa l activity Lis t B . Take additional medicatio n C . Be unable to pr aror ;n the u
---t-iTrnlrn

- nom t of work that you could nnrnally Pe_~--form D . 'I L=--i t h is workload level n aisre~ard fati g ue) E . Be tmao~ to per-=or, n your usu al 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 rccmp . 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 =' JD ER = 5 F" _r-- X' 16- L- : :< G G1 at : p L' : G~ G f ~ ( t^ . . R . . 0 fx+ U3 , 0 .5=~ie _T-~,V 40

_-.-DKAF . CD T-=--,

_ 1 01 'D ,D I ~l jol I0 I/ ~ Sc.~~S ^_

:• `? ~C~cc=~~ ~ 

# 1 I 2

# = Li gil 

# ~ LT ^ 

# ec~ L- - 

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# ,sl (c= 7 

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C= A rin 

# c=,~y~~o~ 1 a

- 

# zj~~~~

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### f ~=

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# , ~ ~in~^ ~ ` ► 1~~ ~r, /~~ ZL~I 7/ t , `~?l 1 t ~ 1 r7---Z 

### 2 c I "

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## l l

r- ---• - - - .`° / ( ~ t ( i l , 

# S C-1,

_ ._ . ( 

# G _ _) 

# (,~2

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# -= 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- ed ica.tien : . Be t
- :b 1e to pre=orm the a., rci nzt of wor k t:~

. =- you coul d nor~l 7 perform

~ . 2llr .i this workload le
-.rel ac~~Zi (a. :Lsre~erd fat=,;se ) Be lma .Die to pe, .=orn your us'u .?! 

### work ac t -V---t-7 or of DreCLC~?~T ~j (* or : :-=ac-. on, 

### househol d S a v at home 

### sick (lose sic?c 

### time r-rm r'_1) %_ s 7 

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

## c ~-~CUP



## _ 

# t t r ~ ~~Z t~l • ~~ S- UZ'` JE L 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 ~ •

=_ ,! : D EF ?_ E U : E- U . c1 c : 1 1 E ~ 0\c tHLZ cr . c--• C/I ^ c~r c tr .+ c n X ~• I0 5__

### ~ 1C= : J= ~ =v=~~ ' . ~ ~ 1 1 .~- E _'- y , T -i ZO

# L C-l 

# _ f s- , a 12o 2~I r i~!~o (J , , ~ ve_ T 1 ' _~ 

# ; 11, 5 

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. : 1= J I

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. VC . . r, , VC-

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

~t
- - - .- ;, ;

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# 10, n `- (

# o- i n) U\



# ~ O22H t 

# ! as tad S2~T 'crc! 

### hcu-rs a

### ul .d they = -use 

### you to

. , . - Decrease ootiorj :- -"i or recr °

. eticrall ac- : --*-I-i[ :-7 L is t 

### Take additional medicatio n

. Be able to preTor ai 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 ) s La-v a t t1CI : '

.L . sic_{ (I CSe S i ck t'TT'P r--= C-,c r_C ) V ; -s- ycL

. p~~7s-c= n V -, -- ' an rv=p . 59

I~ I .j&M

## c: r I! ' 

## II! DP' Borg Exertio n 

### COND . Sc :1 e N M SC VLL tTIZ '~' ; Z (!] G] CJ7 c'~ 1 o L LI1 Q 

### H H =I 1 

### ! F H ~ v n cn Er cn I I G~ Cr cn at a 

### j

_ 

### 5= ~~ ^_ CZ- 3G=S 71-W=-%F 

### x: 

# W g ! c o 

# a-1 G -N+ `~"' • J 

# P + F 

# P0 . 5° 77 e1" y, ve_ 7 1Q=`~

.~ '-W= ENC-Ap . 1 Little M

# u GH 57J5J5 OO 

# 1, /

# 01 5 

# 1 1 - ver_31 ; a, 

# ,! I : z7,jT T- 

# -~ Is Is I 1 ~ f~ , ;~ ~ 1 1{ 1{ 2

# = L

# ; gh

# t `~c -~?.-

, nj ~~ =EZ- 5 t III

-- to 5

_ *~o=-,v 

# c 7 7



# 5'

_ V

# e

_ ;

_ 

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

# ~ _-~~~-`=~y ! ; ► - r= 7 ; 

# :

_--~ , r- _ j , f ~ • i ! ~



# I -- - - .- ,



# f~1 1 ILLH 

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

### !0t o Dec=ease optional or recreational activity Lis t Take additional medicatio n Be = able to preform the arrnmt of work that you could normally perform this w-orikload level down a( isre gard fatigue )



### . Be unable 

### to perform 

### your 

### usua 

### l wo 

### rk 

### activity or level of pro du 

### ctivity (* occuc ation, schcolw ork , cri tical household duties ) S~-av at-- home sick (lose sick time from u,-ork ) visi ~-- ycur Fhysic~ : . V= i

-- an erergercy rcc.np . 60 u~" l .`_ ~l w`vf =_ I ✓ / 5~ 3 

# M .JUr l~ 111 F 

### SUBJECT 1\10 . 

# ~r? D= p~1 Exe r _tion ~ COND . N M Scale SCOR_ ,TG y~ ~ w' 2( cwn ~ ~ ,-a C14 0=~Io t?- :n 1=~r M 20 ~JJDFRATE H H a F z ; E, H g cn cn C n cn at all 5=TRACE 30=SF

.VFnE 

### vI 10== 40=INCAP . 0 .5=Very,Very Littl e COUM 

# II ZD1201 ~ 

# 127 D 1 

# - ZU12 

# 012 d, 1 f C ~ 1= Very light 

# s RMJ-M 12= Lig~nt 15- 

### S UB S =E I'?QL SCR = S DR ?SvA I IES S S C R V T r T D A _ T L to 5= (or M . A -_ R= t~SS> 1 ~ ~ } I 1 , ) , / H ; 

# ~y .roR~ ~ 

### S OF B RF ?'M 

# 1/0 j~ ~ 1 J~ k 

# ~ 5 1 6= haavy : ~Aa % . DI S C< :AJRGE / .~ti~s=!oN 7 to 9 ~ ~ I ~ 1 , I V e 

### r- l _ 

### H G . . .

### avy

~ 

### I

~~~ 

### I 1

~~~ 

### 1 f ~~~ 

### l 1 

### O = Ver

### -7 , VerJ -_"

. . .CT Trl=-1_S/ , 

# = =T?I=N 'r 

# % 0 .177 (7 

# ,

~ti 

# 2 Li_

# '~- : 

# NO I



# ~ c

# -K- _-~ 

# -IN /Z- (0-10 ) if symptoms & di scomtor t 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 ma xLi an amount of work that you could normally per f =orm ) . Turn t

h is workload level wn isre
- ard fatigue ) 

### : . Be unable to perform your usual work activity or level of productivity ( * occ, .mation, schoolw o rk, critical house-hold duties ) Stay at home sick ( lose sick ti me from work) Visiy your physicia n 

### Visit an 

### E-n- er 

### g eTcy roomp .61 C~Ou'P ~ I ✓ v (~ 1 1(l~~~- ~~ SUB .JECT i u . 0, Z 

### DAT E Borg COND . E Yertion r-I N M Scal e SCORING H~~~ 1=71',MIE 20=

_\,DDE~,?TE P. .-i F- r{ H N H M c-x-! 

### 0=\TOthing --~-- ~ [ :~ ~cn c,r ,~ at all- 5='I~?C'S 30=5 ,v ~ -~. X 1-~ a a ~ 10-- = 

### _~ 40=~CA~' . 1 

### 0 . 5=Very, Ve~-T Littl e 

## c o u U - 1 

# 1 / 0 1z 1 1= Q S~~~ I I Very 1 

## ;

_g 

### nt 

# 2= Lig~j

# t S'c3 

## SEAL SOF~~r

.r S OR pSv?~IES S 3= I1b derate SCR E =R~_= 4 (or F .C:-`_ .S~IF .SS) to , 5 =



# , 1 I 1 i 1~ 1 ~ ~ ; ~ 1 1 j S c-LL! E w 

# :at S 

# : oR_IES 

# s or BREA



# ~~ H eavy

1 

# 3 0! 16 = 

# _ ~ Heavy ~~ T D 1: 

# 1 ; ~oa = ~_- N Ve=1 'r' .ea ,- i -~ Ve~--~ 

# _~~T I lo= Ve r : :=S7 

# T 

# c T- r r~

_ 

# ,1_ T0 N 

### E e 

### :w 

# _Z%

-- - 4,-

1L^_C C C'` " i NIS 1 7Q7

# ) :~ S l ;i . G 7\ 7 C-A T 

# . ~ ~ - 

# ~-~ 10 ) s~VIIiDL"Irs & disc~Ltor t _a.s t ed several hcurs, -o

### u1d 

### they cause 

## you r 

## ` t o
~' .~ Y }-r . -u • . ~ _ ( Decrease optional or recre ~--_ tional activity List 3 . Take additi .ona l medicatio n 1 . Be Lmaole to preform the ma ..-d=un a mtmt of work that you could normally perform D . Turn this wor 'k-l oad level acwn isre~ard fati g ue )
~ . Be = b1e to perform your usual work- activity or level of productivity ('' ' oce ..roat ;or

., schoolw o rk, critical household duties ) S iay at home s i ck (lose sick time from G~rk) Vi sic ycur pn, ., s i c - n Vis_ ~_- a ; . E~~r_°^c 7 rcc~

### p .62 GROUP 

# , „ sas sJS.1ECT m 

## d DATE O 

### LcertloII 

### Scale COM . r-4 ` n 

### SCORING 

### ~, ~ ; ( H ~+ ~, ►- CrI 

### ~- O=Vot' 1= 11U 

### NE 20 =

% .D 

### D ERATE H H r_~ H Z~ H H 

### U cn m cn cn cn at all

, , '

- 0 5=TRACE 30=5 r V~~ . r= c ~ c c a c : . ; a w a P . Pcn ile _ 10=`~D 40=~

T i= CAP . 0 . 5I rY,Ve'~y LittL e 

### CO = 1= Very lig ht 

# SPUMI 

# ~{ I '' 2= Li 

### g~it SZJBS =I TAT SQR=- j 

### DR AZ T A_IESS 3= Yb derate 30 Fi 4 to 5 = (or HOA -R . .'SS) lit Heavy 7HOR

_ 1 SS OF BR a= 

# + 6= ve.:z,y 1A SAL 

### DIS CH



### ARGE 

# :~~-~ST_0 N 

# ' ~ to Q ° t 1 

# . Very r eavy vr =12 IG 110= Very, Very :HEST TI~~~SS~ Heavy ? .EST'tZICTION

, 

### ai'IC'-il~


### =E= 

# ON =ST) 7 ;oRC E- R=

oi 1 

### ;C~J~r 

# (0- 1 

# 0 ) if syamtcss 

### & discomfor t as ted 

### several ho

### i--- s, =seyout o

y 

### Decrease optional or recreational activity List Take additional medicatio n Be mable to preform the ma-mm a nou mt of wor k that you could normally perform ) . M= t

his workl oad level w"n (disre cr ard 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) Vis 

### i t your phys 

### l c 

### im room- - - -- ---- i , p . 63

-} L =cCL~ • ,~1~ , t` 

# 3 u~LTrCi ci 

# E 

# ~ 4 ;tt h_,~~ ~ t t ~cr, 

## ~~^r (Q 7

~ '~ 2 ~~° ~Grl 1111 :2 N D . 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 =v1D E~A

=1 cr! 4 U

L z : 1 F- E- C ~ -l~ ~ ~-~

^ 3 n ^ r• r X : F- 'yG L X C= i< [= C t C C C= ^~ ._ O . ~='~e- .'^~, V Cr~

.



# .

# 3 LC~ `' I Vez.-

### r 

# I .r1 ,= _T~~t ttt 

# 1 2

# = Lic 

# ;_ ~~~ =

_ ~ _Ty_c .~' ,tt t~ 

# E : - ~= . r 

# c= 20 

# 2 0 12 L 1) :
J,-~ . 

# ,, I ) 

# IzDl~1S1~ ;I~1 C S ~_~,~ ~ t t t 

# ~ ,

~ 2

# D 

# ~, .~

_ _ _ , tt t 

# ==>L _ C~,0 l
( 

# o~ L

# ,, ) 

# ~ ~ ~ ~ 1 ~ I ~ l~ ► ~ t,t s ~~tc-LLs & - ZeQ ScVe'_"S .! hCLi 5 

### -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_c n Ee 

### able to prerorm the mG~ .~m ~u m t of work t:-.at you could norr-o-l ly pe _,=c r -! ~,e) ~i 

### this wcr~_ead level . ecc- z aisrev~d fat :- ; e unable to perform your usual wcr'-"' activity or level of preducti-vi t-7

~-. ~ es) ( occ :~a~on, sc : .col:or_c, c ~t_ca1 household dut • :7~--a

### v at hc ^

. . :_.P sick 

### (lose sic?t t P f=~ u ~r'_c) ~i_ an =-. °,-,~rc' r~C l` . . -- ~-- --m p .64 Iv 

## --~ L 

### G~ -z' C• 

### tt SUBJECT M,
. ~' c~, ~ DATE Boro E~~ertion COto . e--I N E-I I C1 Scale SCOR?,TG ° r o ; c~ w c~ [ F- + 2 cn cn cn ~- . .- ~+ ~1 H r t-+ N H ~xtd C E-, G* 7 

### 1=\ UL1E 20=`3]DE

Z4
--17 H 0='Nothing

~ n p at all M o t r :1 ~ cE ` 5=?~ACD 30=SFV~~, o o a ~ ~~ a at n 10 ~D 40=~ CAp . ~ t 0 . 5 =Very, Very 

### Litt l

### e
- 

## COt;

# Q-1 Spti~M I I' 1- Ve

- y light SLBS T~~I AL SOR=- S ~ ✓ j_~ 2= Li ;nt OR AT, ;?= TFS S ^_ I ! + 5 1 v ~ 

# 5 1 T ~ 3= Moderate Siv,= . Tl- 0 A= r t ~


### = (or / f / 

### - .

~ 4 

### to ', 5

✓ H } LLI S~_~NiZG t ~' °~-=vy S'_ORrT~SS OF BR-A.--'H- 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 , -' 

### Ver-% l .~ i'~ .C . C l ~ 

### ~ l ._+Z .

Q i .:% Heavy

i ~ ~' ) t t

~ , t ( t 

# 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 . .,~ ^or t Ias ted several hol- --s, :vould they cause ycu to ttt~ .~ tlt _ Decrease optional or recreational activity Lis t 3 . Take additional z--Pacii catio n 

### C . Be unable to preform the ma-- dr= aa-ou mt of work that you could normally perform D . Turn this work-1 oad level -n aisre gard fati g ue ) S . Be t z able to per=-orm your usual work activity or level of productivity occimation, sc : .oolwork, critical household duties ) . Stay at home sick (lose sick ti rn,- from work) = . Visit your physicia n
~ . Visit an - = -e -c,,, rccmp 65 SMIT-lax SCORE SHEE T GROUP 

# )DY-1 SUBJECT NO . Borg DATE Exerti COND . r-+ N `'' Scale SCORING CD 1= 0--Nothing n g ~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 10~`~D 40=INCAP . Little COUC H 1= Very light SPUTUM ~( i! ` I I ;~ ;~ ~ 2= Light SUBSTERl

q AL SORENES S 

### OR AIdA

I=

### S 3= N b 

### derate SORE THR O

### AT 4 to ' 

### 5 = (or HOARSENESS) 

### So ai

-- ., ;hat Heavy SHORT = SS OF BREATH 

### ; ( I I~ ~~ I I( ~'' ~~ 6= veavy NA .SAJ~ DISCHARGE/ 7 to 9 CONGESTION = I I \ Very Heavy M-=IN 

### G j I I ( I , I( ~ ~{ I + I I 10= Very, Ver :

= 

### T TIGHTNESS/ g17 

### Heavy RESi t~ZICTIO N FATIGU'E I 1 ~ I I~ I ~ I { I' \ ~ HFe .DACH E FRD~TAL : M YES IRRITATIO N 0 = SYMPZl7NS (LIST) 10 -- -- -`, f t-~ ~ f 

### BORG =

### TION SCA LE ( 0-10 ) If symptoms & discomfort lasted several ho ur s, 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 fati gue ) 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 physicia n H . Visit an ~ : :er - ency room. 66 .

--- 

# ~u P 73 

# uB.rECT r

U 

# . , ATE 

# Bo a E=m --ta

### on M

### ND . ~r ri N <*'7 t••{ i[ ;I ~! 

### Sc.a? e` 

# ,5 3~ 3COR7,4 V] M . " E~' ''+ r= 6 = 0
. r ; +-- 4 c" c* ~ L=M

# r E 20=

# ~D ~ ~~ U 

# a=vat_~T g E-i E- E-

# ' 5 

### ='~ACF _ 

### ~ " '-'
= 

### c o -1 

### at 

# all a cn 

# Lo= =D z 

# .o= = 

# . o . 5=Very, Very MUM 

# ` I~I ~ I I I ~ I I 11= very 

# liQ ~ ~t
~ iZ 

## jB SZ 1• .T4T 

## S G

## pZTz S 

## M 2- I~L ~~lt



### ~ ~ l 

## to 3 

### - I~derat e 

# I{

# .~ to 

# ~

~~ .L ~r~~l

.r'C" ~ i 1 I ' • 

### or M L R .,5 ) it i F4 to ;5 = 

# H e=-1 y i3 

# )Rr ~'~IF .S S OF BR 

# EA= H o= 

## He :~y 

## A c 

## Al , D, c

## a _pR 

## =-.- / % to °_ ,

- Ve-r-y, Ve-~°'j 

### T T1 l ~ ~ ( ~ 0

# - C_I~SS/ - 7 SON i 1 I I' ~ f to vy 

# ~ ~ CU [ ( Ji _u TCr ~ j ] ~ i t i

~ 7 

## =,R=1 'CS V
71 7 a. . ! 

# _) Q 

# ~ I

## e ION 

## I I -AL

## E E 

# (0-lo) I I I~jl + ~ ~ ~, i - syrrotcns & disccmfor Z: 

### ~7 =_sted several hours , D uld t h ey cause you t o Decrease optional or recreational activity List Take additional medicatio n Be 

## unable to preform the m^ 

## xim+ 

## m -m otmt of 

## work that you could normally 

## perform 'I 

## L= this 

## workload level dawn ' aisreQard 

## fatigue ) Be able to perform your usual work activity or level of prod uc tivity ( * cc"mati en, schcolw-or'_{, critical household duties ) S 

## ~ay at home 

## sick ( lose si

## c k t 

## irrL- from Visis 

### your physician Visit an E--le rgency roomp . 6 7 71 =Tip 0 

### V\t TLT&TE :,T MI . POO Irl ~ ril Bcr-_ 

## a> EE 

## n-/7`~6 Ifl , =cnCOND
. r+ c 4 c* i t-i 1 ~ ►_ },

. , .C .l . -17\11r C F+ ~r? C- ~- 1 I 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 i

N l .c'~' . ( 0 5 - 7 E z J 17 r If ' 

# _Ill(I T COME



# - vL~~ - '~! 2= ~r ._ n L 1 . R 

# F5 I

^ =L_= ~_~ . . Cr _~ 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 t o

- ~ . A . Decr`sz op c :Lcr, ;n 1 or recreational activity Lis t 

### B . Take additional medicatio n C . Be ts:~1e to preror~n the ma .- - n = m t of work that you could nor_-~1~y perfor m D . nsZ this w c r_Lc .:d level c.cw (d tsre~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 cHc cl : , 5r'_c, c~ t ;c? ficuserold duties ) = . S tlay at home sick ( lcse sick tzme from u ;cr :c) G . Visi_ yc = p ;

. : ; I c Lan V_slt an rc =I p . 68 GROUT60 

# {~{ SUBJECT 

### M 

# . Bor ; DAM E : mr=,' or CGN ID Scale SL~'G r= r c 1 4 c~--n Cn Cn xt tt a'- ? - ; ~ 

### ~ ~ , Cn r . y, - C I ~- C L E_ { { O=tiCCt1?n~ E_ (1 X Cri 11-

. . . G-_ 1 V ~ ~ at P3 F•+ '- 1 CI] 

### 0 . 5 COUC- 

# z _i lll~ ~' ;,, ~ I 

### - 

# r {, {

.,cE L'rL~ I I I - ve_y I_~z t 

# I2= Lig!, 

# - ~L•~ .~ ._~~~ .,~ .T-- C, ,_ ~,`' '

- ~ _. _ . 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 ~

_



# T~7 1 1!/~, 

# ~ 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 scrZaSt ad s2Verai ' .CL .s , would 

### t

h

### ey cause 

# ycu to 

# ~ ~ 1 {tt, ' ~

~ • . ~ ~ t • ~ . { ~ { --~ I A . De==z : se optic-p al or recr e ation al activity List B . Take additicna? T- d ; cat-f on 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 w c rclcad 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, s c~ .cclwc r :c, hcus el~iold dut_es ) F . S t: :- v at home s i c_ : (lose s ;c'_c tfrre f_-otn work) C . Visl- vct r H . V sit a- ~ ~r ; rcc~

~~ :P . 69

~/ n~' ✓ ~~ '~ SYMPMM SCORE SET GROU P 

## sus.TECr NO 

## . l ~

t DATE Borg Exertion COND . o , r-+ N M Scale SCORIN G 1= 11UNE 20=~JDERATE p; Cl) ; l , 0 Nothing o at all M 

### 5=TRACE 30=Sr VEIZE a Cr . 

### 10=~ LD 

### 40=I N

### CAP . 0 . 5 Very, Very Littl e 

### COUC H



### _ _ ✓ I 5- 

### , ;- 1 

### '~ 1 

# D I (I;- t i 1= Very light 

### SPUTLIM p /"- 

### 2= Light SUBS TEP

### I 1



### AL SORENES S 

### OR AI q AR . 2',SS 3= N bderate SORE 'II HRiJAT 4to ,5- (or HOA .RSII NESS ) Somewhat Heavy SHORT M 

### SS OF BREATH 

# h 6='Heavy NASAL 

### DIS .ARCE / C01~~ .5''ION 7 

### to 9 = () ! . 1 Very Heavy W=ING 10= Very, Very = T TIGifiLNESS/ ✓ ~ ' ~ Heavy RESTRICTION FATI r 0 T ~ YES ~~~

~ ~~) oTI 41-r --D . S =

N S 

### (LIST ) BORG E .'ZTION SCALE ( 0-10 ) If sy = toms & discomfor t lasted several hours, ~ ` n ;+-~ ~ ► ~ ~ ~~ would they cause you t o
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

- hysic iar. H . Visit an (L-" :er cY ency rcomp . 70 S,~

_ 

# T _Ci•_ ~ . . :r

. ._ . „__._ 

### C~`UP

, 

# Fo BJE„r"i r ;a . ?crDP " F-- Cc= CrJ1V-?i . z~~i ? S z a N t`"1 C=• .- ~1~ C ~ (/] C 4 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 = M A

CE 3 G=r_

.' 7E ti 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 = or 4 l as t ed S2Ve?',1 h cL -- S, 2 t t . ~ wauid they ca-use you to A . Dec : ;-.se ont-_onal- or re_r°~t~or~1 acr-± :vic-,7 List B . lakee additional medicatio n 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 (aisie gard f~

: .t=~~e ) E . Be i~+-aDi .e to F e_,=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 fro m G . Va

- .s vcur c c n rs i c= .=n ~ H . V~ an e^~ er ^e-c ., ~ rcc .n ~~
.p .71 S L-ITTC~1 SCORE -Zf=- T 

### G'2i f)U P SUB .3ECT M . /(0- 0 DATE Bor g

Z Exertion mm . Scale

~ r--1 N M c-+ H 

### ~ t~ ~+~D ~ 7 SW L~IIYG F--1 < C!) C!1 Cf] 1 ' O=Vot_h~ng ♦ C/1 U r--4 U U M l= E 20 ~DERAT . ~' U3 Z U) o I I c~n cHn at al l ~ o o 5=TRACE 30=5 FEV E, , F . w 

### t 10 `^~.,D 40= LNCAP . . 5=1ery, Ver Little •~ , ~ COUG H Sn-m 

# ~ S 

### ~'3ST"~?T• L



### aT SORE-,T-SS 

# 2= Li a

# ht
l ~ DR . cQT.1 ltl J .?= 1~1Jde_"a te l .1Ri TFERDA i' + + 4 to ' 5

_

~ __ ~ ( I I 'C r -L a ~~ JCD L .' -S ) 1 I ~- 7 ~ ~ . , I 1~ ~ I`• .C•.C, .T~~vi__ ^Ocv.`r'~LSS OF BBEL~~ .= 

### --)N ~ST=c N ! f~ ro~ 7 to 9
ve=- : = .~T TTC- . r aa v J _2 

# •~ ~ f ;''~ i (
• ~ ~.-- . , . , _' 

# a =- 

# C = 

# -7 -~- ti 

# -L = : ~ 

# -
S'r-u~ ~ ;~, ",7S i I _~ E :=i-, _CI

N 

### _ synmtoms & discomfort =sted several hours, ~uld they cause you to Decrease optional or recreational activity List Take additional r,~e dicatio n 

### Be unable to preform the ma .d s= = imt of work that you could normally Turn. this workload level do dlsre~ard fati g ue ) Be unable to perform your usual work activity or level of productivity (* occ .mation, school wo rk, c---4t- :cal house :r .old duties ) Sr-ay at home sic!-, ( lose sick time from w ork) F• Visit your physician Visit an EIle_"~~'__C~T roCTTl
~- ~ /p . 7 2 

## ~ovp~ ~ ( _ ► ~j ~



# { .73

## a JE

## cr rU 

## Gv Borg ~ATE ~ C '

. , - ' ,- Exertion -ti .on 

### M 1VD . r-+ N c n ~~-+ ~ r Sca1e .CORING ~ t M ~ ; I ~- : c*~ O=~Tot
~ U
. 

### =~IONE 20-`~DD~RATE ' ; 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 'JU M Very libnt J'1'C~2 711 t) PC) f 2= Light BST~',~T•.iAf SOR~=

~S ~ 3= Moderate 1 ~



### = y Tr=RD? T to 5 = -- ' . O A -Q .S' "L~SS) Heavy JRr'SS OF BREaT'd i 16= Lzatiy _'P7 D 1 : 17 C :I ?RGF

_ NGE S 

### iION 7 to ° _ i) t ✓ ~ ~ Ver-I Heavy 

### ~Z L

### TG 

## 2 .~ 

# 4 1~ 1 y/1U IJ -~1 /~ 2~ I~I ~~ ~~ . ~ ✓ ~ I I I I 1'J= Very y Very 

### :=:ST TI C-

: 

### -'T~SS / ~CTION 

# J
7 N-rr 

### , T 'NO 1=1 Z 

### ~ •,~ ! l~-~~/,( ~V~,', ~ ,~ ~4~ ~ I 

# -~~ 0 N



### _ -R 

### S 7 _MS" 

### ' M 

### NS 

### E = 

### T_o N (0-10 ) __'`~ P• ~ _" ~, ~ 

### syarotoms & 

### discomfor t

_ z: ed several hours , d they cause you t o Decrease optional or recreational activity List Take additional medicatio n Be unable to preform the ma -ds rnun amount ',f wor'_~ . that you could normally perform Turn this w-or'~c .load level ti isre x ard ati zue ) Be unable to perform your usual work acti tv or level of productivit y ;J occupation, schoolwork, critical house_ old duties) ~LAJ~ Stay at hct

r,e sick ( lose sick time from work ) 

### :'isit yc= physic i = isit an er .eroenc`,7 rocIa ~~1 `~~_ L 1•_ti • ~ Jp . 73 s 

# 'TTc

# H '. SCORE S=- 6 v2 ~
VlWTUr ~ I l J V D . J - E C L M
. 

## , ~. D,4=, 

### Borg E :mr . -~oI I n n SC= e COND . r N c- sz i~~_ 1-7 111 7 SCD =j, ;G c z cn cn c n Tr '(
- H r F- N F- c n G I( C : 0 Vot :`L~Q E- E- F- 1 1 v 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 : _ Tc C~R ~`~lL.~~

.J OF R`Ci_=_= 

# l J 

### __ ~ I 

### ~I~ ~ I ~`_^-_~ / ! I ~~~-T D IS 17 

### to G ~ -

~ - VE=- . _ °

.=v 7 

## w E 

## -- ~ V=;,, V e-- T 

# ~_ . ~~~ -- =7 

## c=~-C=--~•= 

# ; / 

# -~~J 

# 5',5
~

~-_~~• • / / ~ / ~ I I I i I ` I I

~ ~ .i'(' .~'•=•~ .- ' . :i~ I I I If s -= tcss & disc . .^ =Ll or r lasred several hot = s, w 7)u1d t hey cause you t o .~ ~ • , A . Decrease option a l or recreational activity Lis t 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 ( a i-s re~ard fatigue ) B . Be unable to perform your usual work activit y or level of producfivit,T (J oc"mation, sc :~-icol w-o r' -, c, critical household dut;es ) F . S L7
-- v at hcme sic -`{ (lose sick, t ; m- from work) C . v ycLr ph 17 s- ci.=n H . V_ an E . n r ~cy rccm

~-p . 74 GROUP 

# SUB A

# CT M 

# . Borg DATE 

# -~5 ZO 

### ,

1311 Exertion COND
. 

### ! r+ N M Scale 

### SCORING

. 

### ~ ~_
~ 5 H r-~ i-i N F-1 c n a 0 O VothlSl g =- 1=NONE 2o=`~JDFRaTE c c 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 S 7j7B

### STEF1, 

### !aL SC 

# R, ~

; " DR A MA-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 = ST TICr~_1ESS/ HeaW ZFS TRICTION 

# ' ► ' ~



# 17 

# ; l ~! 1i 1 ~~!!1 l 

# ! :Ej_1 ll " 

# ~~-~~L :~ Y~ ~~ I I~~ C 1~ ► ~ ~ !

±±WTT1'

JT'r-~ . .~ s L", : V N S 

### 30K- E~T?"ON 

# s C 

# '~J-7 (0-10 ) If syrimtcros & discomfor t Lasted several ho ur s , Vo uld they cause you to ;,- k . Decrease optional or recreational activitT 7 Lis t 3 . Take additional medicatio n 

### 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 g ue ) 7 . Be unable to perform, your usual work activity or level of productivity oce, . .mation, schoolwor k , 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 ;L- 't I Su'B .~ ~CT I~ . BOr~ L1-°T^ 

## S

~ 

## 7 G ~ ~cr? COND . ca cn Sc e S L0=1 lC cn C!7 C!1 ' d ~ ~ ~_, r
► = C14 cr1 , O=~TC L :17 ; T , . ° 1=~? J L~- ~D~c U1 E~' C U C~ C5 F E" = " C t

✓ ` ~-' U : V'_ Vl c { C= cn t!] - ct- c ^ D 0 r , ^' C C ^- ~ 5 ~-_~ .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 la S ed, s eV2r? ~ i='to A . De--re= e optional or recreational ac r, :-,L v -- CT Lis ` B . T alc--- additional u~^ ~ cur=cn C . Be unanle to preform tie ~a :=-m m ~mt oz w o r'_c tna t you could r o rmallv peYorm D . 'I=_ this workload level cncV~i (aisre~,d fat_g+ 1 e) E . -Be ~bie to pe

_

per-- ;-o= yc = us-~1 wz~r : c ec =4,v it-r or level of precx :etivf . .t l cc: :-= et a cn, s~:ccl~~~r:, cr ;+-c~ 1 household du~es ) F' C i ? ~T ac : 17

. C' .'_'O s i c -,~ ( ic se s - c k •'T'Q 

### from G-c r k ) \ ~ 1 ( ` o n x . V J~ ~/l~ v ~ 1- f v / ._.. ,~ .. -~ , - - -- • 7 ~- y S)2*' I M SCORE SHEE T 

### GROUP StJB.TECT 1,7

0 . DATE Borg Exertion COND • c~ ~ N M Scale SCORIN G 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 COUC H 

### ' 1= Very light SPUTUM ~ I ~ I sUBS TE RI :AL SORENESS L L2=u t OR A W AR~' = / ( l ` ~ 1 1 I l' ' l 

### 3= ~b derate SORE THROAT 4 to 5 = (or HOARS~IESS) Somewha t

. Heavy

OF BREAgI

~ 16= -Heavy NA~a .L DISCHARCE / M NC'~STION to 9 tiv r r ' ' Very Heavy Z I N G 10= Very, Very Heavy RESTRICTIO N

~ 

### = ~-- -G UT 

# FIT , , _-~~A =


### S ) S~?~ ICNS T BORG EXERTION i' ~ SCALE (0-10) "' \l _f 

### symptoms & discomfor t _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 . T urn this workload level ~disregard fatigue ) ~ . Be unable to perform yo ur 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


# ~ .~ i~- `~ ✓
/ t 

### S M 

### ! ~ .r~'i" NO
. 

### ; F-- ~ ~CIl COND
. C.': 1 Z .^ L G 21 1 N C^ 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 . cn c 

### 10= :~ '[ 0= ~~ p 0 . S=Ve_,--J_ VEry C

# O UG H 

### Sru
- Ri'v- I 1= Ve= y

C " '==' ~

' .~•_- I , 1 ~ I ~ ~ I 1 t\ --- _~~ . . : ; tli ' _ --*_ f~ r- t i t -

-

_ (Cr t : ~ = ~ •.--- f . ~ ~ I ~ I t

_ _ _ • I . - =_L'L~

. . Cr I I I \\\ ~ i -

--- _ti ~ tll i ~

. . .- ~ lll

--- ~l~ 

# _~~_ 

# 11 1-5 1

__. ~_l . '. a

✓ ,r \-c ' ~ ` ~ I ' 1 ~ ; ~ ~ I i i ' ; - .,- -y ._, 

# -_-= = = ~ t ~ ~ 1 I 1 

# I 1 1 ==-==_=~ ~_-~ ;~ \ i~~ ; 4~~ ; ; ' ; I1I I 

# _ •,- -' I ; • -~ ~ ii i



# \ ~~ ► ~ I'D 

# ;~,b~~~~ s, ._,t :--, & 

### „t I

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

---

_ asted se v

eral 1- .01 r- s ,culd t :`iey cause you te I l t Decrease opt=ornal or recreational activity Lis t Take additional medicatio n 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'
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## L I I i I I I I I~ E?',- IRRITATION PEST H Oi'~r= :R =1 , MINUTE VOLUME S PACK YEA R 

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# H

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- n 1w no 2 w'O O

o o o 'r" r' ^ ' 1~ I C C :>< y`~ SUBJECT NUMBER 

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# i ;= ~ - -0 - .0 C D ~-N-I I- I M ; o , • GROUP NUMBER GROUP NUMBER

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### I I I 

## &1+AjTT-pd SP~UM I F

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### 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

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