Document 3eV21kQ6OweXLmjM9YBBpqj4x

Federal Register / Vol. 51, No. 119 / Friday, June 20,1986 / Rules and Regulations Any chest operations? If yea, please epeeify Any ehest injuries? 1. res _ 2. Mo __ If yes. please specify 27A. Has a. doctor ever told you that you bad heart trouble? 1. Yes __ 2. Wo __ IP YES TO 27A: 8. Have you evet bad treatment for heart trouble in the past 10 years? Apply __ 28A. Has a doctor ever told you that you bad high blood pressure? 1. Yes'__ IK YES TO 28A: .. B. Have you had any treatment for high blood pressure (hypertension) in the past 10 years? 1. Yes __j, . 2. No __ i. Does wot Apply __ 29. when did you last have your chest X-rayed? (Year) 25 n Tf 28 10. Where did you last have .your chest X-rayed (if known)? ------- ' --_ What was'the outcome? ' PAHILY HISTORY 31. Were either of your natural parents ever told by a doctor that they bad a ehrooic lung condition such as:' FATHER 1. Yes 2. No f. Don't Know 1. Yes MOTHER 2. Wo 3. Don't Know A. Chronic Bronchitis? ' ____ ___ ____ B. Emphysema? . __ -- ----- . ---- ---- C. Asthma? ____ . _ . -- ____ _ D. Lung cancer? E. Other chest conditions ___ ___ ____ T. is parent currently alive? G. Please Specify ___ Age if Living __ Age at Oeath Don't Know - : if Living k at Death t Know H. Please specify eause of death COUGH 32A. Do you usually have a cough? (Count a cougn with first smoke or on first going out of doors. ' Exclude clearing of throat.) (If no. skip to question 32C.} B. Do you usually cough as much as to 6 times a day.4 or more days out of the week? 1. Te _ 2. No _ C. Do you usually cough at all on getting up or first thing in the morning? 1. Yes. 2. No __ D. Do you usually cough at all during the re6t of the day or at night? l. Yes 2. NO _,, IP YES TO AMY OF ABOVE (32A. B. C,,or D). ANSWER THE FOLLOWING. IP NO TO ALL. CHECK DOES MOT APPLY AMD SKIP TO NEXT PAGE E. Do you usually cough like this on most days for 3 consecutive months or more during the year? 1. Yes 2. NO 3. Does not apply P. For how many years have you had the cough? Number of years Does not apply 33A. Do you usually bring up phlegm from your chest? (Count phlegm with the first smoke or on first going out of doors. Exclude phlegm from the nose. Count swallowed phlegm.) (If no. skip to 33C) l. Yes __ 2. no _ B. Do you usually bring up phlegm like this as much as twice a day e or more days out of the week? l. Yes __ 2. no _ C. Do you usually bring up phlegm at all on getting up or first thing in the morning? 1. Yes _ 0. Do you usually bring up phlegm at all during the rest of the day or at night? 1. Yes _ IK YES TO AMY OP THE ABOVE (33A. B. C. or D). ANSWER THE FOLLOWING: IP NO TO ALL. CHECK DOES NOT APPLY AND SKIP TO 3A. E. Do you bring up phlegm like this on most days for 3 consecutive (tooths or more during the year? 1. Yes __ 2. No 3. Does not apply ft_V- GLEASON-000997