Document dYML6y83YKYJGY91rRe51eN0q

22750 Federal Register / Vol. 51. No. 119 / Friday, June 20,1986 / Rules and Regulations K. Kor bow many, yearshave you had trouble with phlegm? or episodes couch'awd~. phlegm J ' 34 A1 Have you had periods or episodes of (in creased*) cough .S'nd'phlegm lasting for 3 weeks or more, each-year 7 a(E.or persons who. usually have cough and/orphlegm) !t YES TO 34A. B.. Kor how long nave -you had'at least l such episode per year? .... WHEELING 3SA. Does your chest' ever sound wheezy or - whistling 1. When you nave a/cold? '2. Occasionally apart iron colds? 3. Most days ornigtits? IK YES TO 1. 2.. or 3. in 35A B. Kor now many years his this-been present? 36A. Have you;evr had an attack of wheezing that nag made you feel short.ot breatn? IK YES TO 36A B. How-old were you whenyou had yotjr tied such attack? . ' _ c. Have you had .2 lot .more such episodes? - D. Have yog ever'required medicine or - treatment for- the.(se) attack(s)? ' BREATHLESSNESS'- J \.r ;' 37..- it.-disabi.ed;tcom.witxinq by..any condition. v other.than.heart or lung disease, please describe and -proceed .to question. 39A.. . ` . Natuco- ot eoudi-i tiori( 6) ~ - - 3ba. Are you'troubled by shortnece of '-breatn. when .nuriyinq on-the -level or walking up a-; 'slight .hill? ' Number of years Does not apply \. Yes _ 2.. No Number of'years Doe8 not apply l. Yes ___ .1. Yes __ 1. Yes __ .2. No ___ 2. No __ 2. no -_ Number of years __ .Does oot apply. _ 1. Yes __ 2. No _ Age in years __ Does oot apply _ i. ires __ 2. no ___ 3. Does not apply __ L. Yes ___ 2. No ___ 3. Does not apply- __ 1. Yes __ 2. No __ IK YES TO 3BA b. Do you nave to walk slower than people ot your age on the level because ot bceatnles::iiu3S? C. Do you ever nave'to stop tor breath when walking at your own pace on' the level? D. Do you ever have to stop tor breath alter watkinq about 100 yards (or alter a tew minutes) on the level? E. Ace you too breathless to leave the house or breathless on dressing oc climbing one tliqht ol Sldir6? TOBACCO SMOKING 39A. Have you ever smoked cigarettes? (No means less than 20 packs ot cigarettes or 12 oz: of tobacco in a lifetime or les: than l cigarette a day (or l year.) IK YE5 TO 39A D. Do you now smoko cigarettes (as of one month ago) c. How old were you wnen you first started regular ciqarette smoking? u. it you nave stopped smoking cigarettes completely, how old were: you when you stopped? E. How many cigarettes do you smoke per day now? p. On the averaqe of the entire time you smoked, how many cigarettes'did you - smoke'per-day? G. 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 __ 21 No __ j. Does not apply ___ 1. Yes __ 2. No __ 3. Does not apply _ 1. Yes ^ 2. No 3. Does not apply l. Yes __ 2. No l. Yes __ 2. No . Does not apply Age iu 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 ___ GLEASON-000998