Please check those that apply to you.
Do you get short of breath during the following activities?
|
__At rest
__Eating
__Simple personal care
__Taking full bath/shower
__Dressing
__Picking up/straightening up
__Sweeping/vacuuming
__Shopping |
__Laundry
__Climbing stairs
__Cooking/doing dishes
__Walking around your house
__Walking at your own pace on level surface
__Walking one block
__Walking up a slight hill |
What activities does your breathing difficulty prevent you from doing that you would like to do?
Do you sometimes have coughing or breathing attacks when exerting yourself - for instance, when walking up stairs, taking a shower? __Yes __ No
Do you smoke? Have you smoked for a long period of time? __ Yes __ No
Do you have frequent bouts with bronchitis? __ Yes __ No
Do you have morning coughing fits? __ Yes __ No
Do you cough up greenish yellow sputum? __ Yes __ No
Do the following things limit your ability to remain active?
|
|
___Shortness of breath
___Fatigue
___Lightheadedness |
If you checked YES more than 2 times…Ask your doctor for a COPD/rehabilitation evaluation or give us a call today.
Pulmonary Rehabilitation And Asthma
Education Center – (859)-301-5750
