Respiratory Symptom Evaluation

1 2 3 4 5

Do you experience
morning cough with mucus?

1Every day (all 30 days out of the last 30 days)

2Most days (16-29 days)

3Occasionally (6-15 days)

4Rarely (1-5 days)

5Never (0 days out of the last 30 days)

1 2 3 4 5

Do you cough frequently
throughout the day?

1Every day (all 30 days out of the last 30 days)

2Most days (16-29 days)

3Occasionally (6-15 days)

4Rarely (1-5 days)

5Never (0 days out of the last 30 days)

1 2 3 4 5

Do you feel breathless while doing activities like walking up a flight of stairs or carrying a heavy object?

1Every day (all 30 days out of the last 30 days)

2Most days (16-29 days)

3Occasionally (6-15 days)

4Rarely (1-5 days)

5Never (0 days out of the last 30 days)

1 2 3 4 5

Do day to day activities like doing laundry or buying groceries tire you?

1Every day (all 30 days out of the last 30 days)

2Most days (16-29 days)

3Occasionally (6-15 days)

4Rarely (1-5 days)

5Never (0 days out of the last 30 days)

1 2 3 4 5

Do you experience wheezing or whistling in your chest at times when you are not doing any physical activity?

1Every day (all 30 days out of the last 30 days)

2Most days (16-29 days)

3Occasionally (6-15 days)

4Rarely (1-5 days)

5Never (0 days out of the last 30 days)

Patient Support - Respiratory Symptom Evaluation

Do you experience
morning cough with mucus?

Do you cough frequently
throughout the day?

Do you feel breathless while doing activities like walking up a flight of stairs or carrying a heavy object?

Do day to day activities like doing laundry or buying groceries tire you?

Do you experience wheezing or whistling in your chest at times when you are not doing any physical activity?

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Patient Support - Respiratory Symptom Evaluation

Do you experience morning cough with mucus?

Do you cough frequently throughout the day?

Do you feel breathless while doing activities like walking up a flight of stairs or carrying a heavy object?

Do day to day activities like doing laundry or buying groceries tire you?

Do you experience wheezing or whistling in your chest at times when you are not doing any physical activity?

Do you experience
morning cough with mucus?

Do you cough frequently
throughout the day?