Document RJjkgkaLYvEvzYMBomR2bJ7GX

/Federal Register / Vol. 51. No. 119 / Friday. June 20,1986 Rules and Regulations B. Any chest operations? 1. Yes 2.. No If yes. please specify C. Any ehest injuries? 1. Yes 2. No If yes. please specify 27A. Has a. doctor ever told you that you bad heart trouble? 1. Yes __ 2. No __ IP YES TO 27A: B. Have you ever bad treatment for heart trouble in the past 10 years? 2flA. Has a doctor ever told you that -you had high blood pressure? 1. Yes __ 2. No __; 3. Does Not Apply __ i. res- _ 2. No _ IP YES TO 28A: .. B. Have you had any treatment for high blood pressure (hypertension) io the past 10 years? 1. Yes ^ j 2. No __ 3. Does Not Apply _ 29. When did you last have your chest X-rayed? (Year) _ __ 2 S 26 __ __ 27. 28 30. Where did you last have .your chest .X-rayed (if known)? What was' the outcome? PAMILY-HISTORY 31. Were either of your natural parents ever told by a doctor that they had a chronic lung condition such as:FATHER 1. Yes ` 2. No 3. Don't Know 1. Yes KOTKEB 2. No 3. Don't Know A. Chronic Bronchitis? , ------ ------ B. Emphysema? C. Asthma? D. Lung cancer? E. Other chest conditions P. is parent currently alive? G. Please specify _ Age if Living Age at Oeath Don't KOOW Age if Living Age at Death Don't Know H. Please specify cause of death COUGH 32A. Do you usually have a cough? (Count a cough with first smoke or on first going out of doors. Exclude clearing of throat.) (If no. skip to question 32C. ] l. Yes No 8. Do you usually cough as much as 4 to 6 times a day.4 or more days out of the week? 1. Yes 2. No __ C. Do you usually cough at all on getting up or first thing in the morning? l. Yes. __ 2. No D. Do you usually cough at all during the rest of tbs day or at night? 1. Yes _ 2. No _ IP Yes TO ANY OF ABOVE (32A. B. C., or D). ANSWER THE FOLLOWING. IP NO TO ALL. CHECK DOES NOT APPLY AND SKIP TO NEXT PAGE B. Do you usually eough like this on most days for 3 consecutive months or more during tbe year?' 1. Yes __ 2. Wo 3. Does not apply __ P. Por how many years have you bad tbe cough? 33A. Do you usually bring up pblega from your chest? (Count phlegm with the first smoke or on first going out of doors.. Exclude phlegm from the ooee. count swallowed phlegm.) (If no. skip to 33C) B. Do you usually bring up phlegm like thie as much as twice a day 4 or more days out of the week? C. Do you usually bring up phlegm at all on getting up or first thing in the morning? 0. Do you usually bring up phlegm at all during the rest of the day or at night? Number of years __ Does nut apply .1 Yes __ 2. NO __ .1 Yes __ 2. NO __ .1 Yes ___ l. Yes __ 2. NO __ .2 NO __ IP YES TO ANY OF THE ABOVE (33A, B. C. or D). ANSWER THE FOLLOWING: IF NO TO ALL. CHECK DOES NOT APPLY AND. SKIP TO 34A. E. Do you bring up phlegm like this on most days for 3 consecutive months or more daring tbs year? l. Yes __ 2. No __ 3. Does not apply _. 22749 GLEASON-000997