Document b5xXB6vYKb3MvQmz5V3kvk846

Federal. Register /. Vol. 51.' No... 119,/ Friday, June 20.1986 / Rules and Regulations K. Koc how many years have you- had' troublewi r.h -.phlegm?. EPISODES OK-COUCH AND PHLEGM' ' '34A. Have-you'had periods or episodes of (in creased*) cough and phlegm.-lasting-for 3 * week* 01 -more each' year7 (for persons .who usually have cough and/or . phlegm) If-YES TO 34A . B. For hovlonq nave you had at leasL^l such episode per year? ' WHEEZING 3SA. odes your chest ever 6ouhd Wheezy ox whistling 1. When you have a cold? 2.' Occasionally apart troa'Colds?. 3. Hoot days, or nightc?. IP res TO 1. 2. or Mn 35A . . B. Kor how- many years-has this been present? 36A.' Have you ever 'had an attack of wheezing thathas'made you feel onort-of breath? IP TBS TO 36A ' *' \ - 0. How.old were you'when you had your first such-attack? C. Have you had 2 or more such episodes? D. Have'you' ever required medicine or' treatment.for the(se)-attack(e)? . BREATHLESSNESS' 3?. if disabled fromwalking by any. condition other than heart or'il'ung disease, please, describe-and . proceed' to-question' 39A.' - Nature of condition(s) . - ' -' 36A. Are you troubled by shortness of breath when hurrying on the'level or walking up a slight hill? Number 1 years Does' not.apply 1. Yes __ 2. No __ .Number, of years 'Does, not' apply. _ i. Yes __ 1. Yes 1. Yes ; 2. No__ 2. No 2. No Number- of years _ Does not apply _ 1. -Yes _. 2. No .Age in years . __ Does not apply ^ i. Yes _L 2. No _ 3, Does not apply __ 1. res __ . 2. No __ 3. Does not apply __ 1. Yes __ 2. No __ IP YES TO 38A - B. Do you have to walk slower than people of your age on the level because of breathlessness? C. Do you ever nave to stop for breath when walking at your own pace on the level? ' p. Do you ever have to stop for breath after walking about loo yards (or after a few minutes) on the level? E. Are you too breathless to leave the bouse or breathless on dressing or climbing one flight of stairs? TOBACCO SMOKING 39A. Have you ever smoked cigarettes? (No means less than 20 packs of cigarettes or 12.oz. of tobacco in a lifetime or less than l cigarette a day for 1 year.) If YES TO 39A B. Do. you now smoke cigarettes (as of one month ago) C. How old were you when you first started regular cigarette smoking? D. If you have stopped smoking-cigarettes completely.- how old were you when you stopped? ' How many cigarettes do you smoke per day now? F. On the average of the entire time you smoked, how many cigarettes did you smoke per day? ' 6. Do or did you inhale the cigarette smoke? 40A. Have you ever smoked a pipe regularly? (Yes means more than 12 oz. of tobacco in a lifetime.) 1. Yes __; 2. No 3. Does not apply 1. Yes __ 2. No 3. Does not apply ;. 1. Yes w 2. No 3. Does not apply l. Yes __ 2. No 3: Does oot apply 1. Yes __ 2. No. 1. Yes __ 2. No 3. Does not apply . Age in years Does not apply Age stopped Check if still smoking Does not apply Cigarettes per day Does not apply Cigarettes per day Does not apply 1. Does not apply. 2. Not at all 3. slightly 4. Moderately 5. Deeply 1. Yes __ 2. No 22773 GLEASON-001021