On average, during the past week, how often did you feel:
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| 1. Short of breath at rest? |
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| 2. Short of breath doing physical activities? |
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| 3. Concerned about getting a cold or your breathing getting worse? |
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| 4. Depressed (down) because of your breathing problems? |
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In general, during the past week, how much of the time:
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| 5. Did you cough? |
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| 6. Did you produce phlegm? |
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Not limited at all
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Very slightly limited
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Slightly limited
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Moderately limited
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Very limited
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Extremely limited
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Totally limited/ or unable to do
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On average, during the past week, how limited were you in these activities because of your breathing problems:
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| 7. Strenuous physical activities (such as climbing stairs, hurrying, doing sports)? |
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| 8. Moderate physical activities (such as walking, house work, carrying things)? |
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| 9. Daily activities at home (such as dressing, washing yourself)? |
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| 10. Social activities (such as talking, being with children, visiting friends/relatives)? |
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Never
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Hardly ever
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A few times
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Several times
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Many times
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A great many times
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Almost all the time
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How often in the past week did you suffer from:
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| 11. Worry? |
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| 12. Listlessness? |
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| 13. A tense feeling? |
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| 14. Fatigue? |
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