Document 5Lp1ZDYKya8y2m2x6V18376Je

Federal Register / Vol. 51, No. 119 / Friday, June 20,1988 / Rules and Regulations B. Any chest operations? c. Any chest injuries?- 1. .Yes __ 2 . No -- 1. Yes __ _2 . No 27A. Has a.doctor ever told you that you'had heart trouble? 1 Yes ^ 2 . No -- IF YES TO 27A: B. Have you ever bad treatment for heart trouble in tne past 10 years? 28A. Has a doctor ever told you that you had high blood pressure? 1. 3. Yes __ Does Not 2. NO Apply - 1. Yes __ 2 . No -r- IF YES TO 28A: B. Have you had any treatment for high blood pressure (hypertension) in the-past 10 years? i. 3. Yes __ Does Not 2. No Apply - 29. When did you last have your chest X-rayed? (Year) __ 2$ 2b. 27 28 30. Where did-you last have your chest -X-rayed (if known)? wh*T was the outcome? FAMILY HISTORY 31. were either of your natural" parents ever told by a doctor that they had chronic lung condition such ac: FATHER 1. yes 2. No 5. Don't Know 1. Yes MOTHER 2. No 3. Don't Know A. Chronic Bronchitis? ____ ' _- ---- ---- B. Emphysema? __ - .v ____ ____ - C. Asthma? - . ___ _ ---- ------ ---- D. Lung cancer? ___ ____ ____ -- ---- 1 ------- E. other chest conditions _ r_ ----- ` -- -- - -- F. Is parent currently alive? G. Please Specify Aoe if Living ___ Age at Death Doo l Know . __ Age if Living __ Age at Death . Don't Know H. Please specify cause ot death COUGH -32A. Do you usually.have a cough? (Count a cough with first umoke or on tirst going out of doors. Exclude clearing ot throat.) {It no, skip lo question 32C.1 l. Yes___ 2. No 8. Do you usually cough as such as 4 to 6 tines a day 4 or note .days out ol the week? 1. Ye* ... 2.-No C. Do you usually cough at all on getting up or first thing in the morning7 i- Yec _ 2. No _ D. Do you usually couqh at all during the rest of tne day.or at night? l. Yec ___ 2. No __ IF YES TO ANY OF AB<5VB (32A. B. C. Or D). ANSWER THE FOLLOWING. IF NO TO ALL. CHECK POES NOT APPLY AND SKIP TO NEXT PAGE E. Do you usually cough like this on nost days for 3 consecutive months or more during the year? 1. Yec __ 2. No __ 3. Does not apply __ F. For now ,many years have you had the cough? Number ot years _ Does not apply __ 33A. Do you usually bring up phleuo iron your chest? (Count phlegm with the first smoke or on first going out of doors. Exclude phlegn from the nose. Count swallowed phlegn.) (If no. skip to 33C) 1. Yes --. 2. No B. Do you usually bring up phlegm like this as much ac twice a day 4 or sore days out of the week? 1. Yes _ 2. No C. Do you usually brinq up phlegm at all on getting up or first thing in the morning? l. Yes _ 2. No _ D. Do you usuallybring up phlegn at all during the rest of the day or at night? l. Yes __ 2. No _ IF YES TO ANY OF TKe ABOVE (33A. B. C. or O). ANSWER THE FOLLOWING: IF NO TO ALL. CHECK DOES NOT APPLY AND SKIP-VO 34A. E. Do you bring up phlegn like this on nost days for. 3 consecutive noutne or nore during the year? l. Yes __ 2. No __ 3. Does not apply _ GLEASON-001020