Attachment 3  Pulmonary Health Questionnaire 

                                                            Form Approved
                                                            OMB no. 0920-0494 
                                                            Exp. Date xx/xx/20xx  

Exposure to Aerosolized Brevetoxin During Red Tide Events
	 Pulmonary Health Questionnaire

	National Center for Environmental Health
	Centers for Disease Control and Prevention

	Florida Department of Health

	University of Miami School of Medicine

Name: 		_________________  _________________  ___________
                        (Last)               (First)   	        (Middle Initial)

Birth Date	: 	_____/_____ 
            		mm  /  yyyy

Current Address:
____________________________________________
                    		(Number, Street, or Rural Route)
____________________________________________

____________________________________________
                    		(City or Town, State, Zip Code)

Home Phone:	(_________) _________ ‑ _________________

Public reporting burden for this collection of information is estimated to vary from 4 to 6 minutes per response, with an average response of 5 minutes, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to:  CDC/ATSDR Reports Clearance Officer; Paperwork Reduction Project (0920-0494); M.S. D-24; 1600 Clifton Road NE, Atlanta, Ga. 30333

1. INTERVIEWER				______________________________

2. DATE OF INTERVIEW ____/____/____
                      mm /dd  / yyyy

3. LOCATION	______________________________
STREET ADDRESS
______________________________
NAME OF BEACH
______________________________
CITY
______________________________
STATE, ZIP                      

4. SEX							
	1. FEMALE
2. MALE

First, I would like to ask a few questions about yourself.

5.  What is your race?	1.  AMERICAN INDIAN, ALASKA NATIVE
2.  ASIAN
3.  BLACK OR AFRICAN AMERICAN
4. NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
5.  WHITE
88.  DON’T KNOW
99.  REFUSED

6.  Are you of Hispanic origin?	1.  NO
2.  YES
88.  DON’T KNOW
99.  REFUSED

7.  How many years of school have you completed?
_____ Number of years
88.  DON’T KNOW
99.  REFUSED

Now, I have a few questions about your heath.

8. Have you ever had asthma?	1.  NO
2.  YES
88.  DON’T KNOW
99.  REFUSED

9. Have you ever had an asthma attack?	1.  NO

2.  YES
88.  DON’T KNOW
99.  REFUSED

IF NO TO BOTH QUESTIONS 8 AND 9, SKIP TO QUESTION 10.

9a. At about what age did the asthma start?	_______ AGE (YEARS)
77.  NA
88.  DON’T KNOW
99.  REFUSED

9b. Was asthma confirmed by a doctor?	1.  NO
2.  YES
77.  NA
88.  DON’T KNOW
99. REFUSED

9c. Do you still have asthma?	1.  NO (GO TO QUESTION 9c1)
2.  YES (GO TO QUESTION 9c2)
77.  NA
88.  DON’T KNOW
99.  REFUSED

 		9c1. How old were you when it stopped?
______ AGE (YEARS)
77.  NA
88.  DON’T KNOW
99.  REFUSED

9c2. Do you now take any medicines, including non-prescription medicines, for asthma?				1.  NO
2.  YES
     SPECIFY	____________________
____________________	 ____________________
____________________
77.  NA
88.  DON’T KNOW
99.  REFUSED

10. Have you ever done any pulmonary function tests?  By pulmonary function tests, I mean spirometry, peak flow, etc.			
	1.  NO
2.  YES
77.  NA
88.  DON’T KNOW
99. REFUSED

Now, I would like to ask you about a series of symptoms, how often you may have had these symptoms, and whether or not they change.

Symptom	
11. Shortness of breath with wheezing or whistling.	
12. Shortness of breath or coughing that came on when you were just lying in bed or not doing any special effort.	
13. Tightness in the chest that lasts for more than 1 minute.	
14. Do you usually have a stuffy nose, or drainage at the back of your nose?	

Have you experienced the symptom?	
1. NO
2. YES	
1. NO
2. YES	
1. NO
2. YES	
1. NO
2. YES	

When did your symptoms first occur?	
____/____/____ (DATE)
mm  dd  yyyy
77. NA
88.  DON’T KNOW
99.  REFUSED	
____/____/____ (DATE)
mm  dd  yyyy
77. NA
88.  DON’T KNOW
99.  REFUSED	
____/____/____ (DATE)
mm  dd  yyyy
77. NA
88.  DON’T KNOW
99.  REFUSED	
____/____/____ (DATE)
mm  dd  yyyy
77. NA
88.  DON’T KNOW
99.  REFUSED	

When was the last time you had these symptoms?	
____/____/____ (DATE)
mm  dd  yyyy
77. NA
88.  DON’T KNOW
99.  REFUSED	
____/____/____ (DATE)
mm  dd  yyyy
77. NA
88.  DON’T KNOW
99.  REFUSED	
____/____/____ (DATE)
mm  dd  yyyy
77. NA
88.  DON’T KNOW
99.  REFUSED	
____/____/____ (DATE)
mm  dd  yyyy
77. NA
88.  DON’T KNOW
99.  REFUSED	

About how often do you have these symptoms?	
1. ONLY ONCE
2. ONLY A FEW DAYS EVER
3. A FEW DAYS EACH YEAR
4. A FEW DAYS EACH MONTH
5. A FEW DAYS EACH WEEK
6. USUALLY AT LEAST ONCE EACH  DAY OR NIGHT
77.  NA
88.  DON’T KNOW
99.  REFUSED	
1. ONLY ONCE
2. ONLY A FEW DAYS EVER
3. A FEW DAYS EACH YEAR
4. A FEW DAYS EACH MONTH
5. A FEW DAYS EACH WEEK
6. USUALLY AT LEAST ONCE EACH  DAY OR NIGHT
77.  NA
88.  DON’T KNOW
99.  REFUSED	
1. ONLY ONCE
2. ONLY A FEW DAYS EVER
3. A FEW DAYS EACH YEAR
4. A FEW DAYS EACH MONTH
5. A FEW DAYS EACH WEEK
6. USUALLY AT LEAST ONCE EACH  DAY OR NIGHT
77.  NA
88.  DON’T KNOW
99.  REFUSED	
1. ONLY ONCE
2. ONLY A FEW TIMES EVER
3. A FEW TIMES EACH YEAR
77.  NA
88.  DON’T KNOW
99.  REFUSED	

	
Shortness of breath with wheezing or whistling.  Continued	
Shortness of breath or coughing that came on when you were just lying in bed or not doing any special effort.  Continued	
Tightness in the chest that lasts for more than 1 minute.  Continued	
Do you usually have a stuffy nose, or drainage at the back of your nose? Continued	

Are/were your symptoms worse during a particular season?	
1.  NO, ABOUT THE SAME IN ALL             SEASONS
2.  WORSE IN SPRING
3.  WORSE IN SUMMER
4.  WORSE IN FALL
5.  WORSE IN WINTER
77.  NA
88.  DON’T KNOW
99.  REFUSED	
1.  NO, ABOUT THE SAME IN ALL             SEASONS
2.  WORSE IN SPRING
3.  WORSE IN SUMMER
4.  WORSE IN FALL
5.  WORSE IN WINTER
77.  NA
88.  DON’T KNOW
99.  REFUSED	
1.  NO, ABOUT THE SAME IN ALL              SEASONS
2.  WORSE IN SPRING
3.  WORSE IN SUMMER
4.  WORSE IN FALL
5.  WORSE IN WINTER
77.  NA
88.  DON’T KNOW
99.  REFUSED	
1.  NO, ABOUT THE SAME IN ALL             SEASONS
2.  WORSE IN SPRING
3.  WORSE IN SUMMER
4.  WORSE IN FALL
5.  WORSE IN WINTER
77.  NA
88.  DON’T KNOW
99.  REFUSED	

Are/were your symptoms worse during a particular time or day or night?	
1.  NO, NOT WORSE AT ANY             SPECIFIC TIME OF DAY OR NIGHT
2. WORSE WHEN I FIRST WAKE UP
3.  WORSE WHILE AT WORK  
4.  WORSE AFTER LEAVING WORK
5.  WORSE WHILE LYING IN BED 
77.  NA
88.  DON’T KNOW
99.  REFUSED	
1.  NO, NOT WORSE AT ANY             SPECIFIC TIME OF DAY OR NIGHT
2. WORSE WHEN I FIRST WAKE UP
3.  WORSE WHILE AT WORK  
4.  WORSE AFTER LEAVING WORK
5.  WORSE WHILE LYING IN BED 
77.  NA
88.  DON’T KNOW
99.  REFUSED	
1.  NO, NOT WORSE AT ANY       SPECIFIC TIME OF DAY OR NIGHT
2. WORSE WHEN I FIRST WAKE UP
3.  WORSE WHILE AT WORK  
4.  WORSE AFTER LEAVING WORK
5.  WORSE WHILE LYING IN BED 
77.  NA
88.  DON’T KNOW
99.  REFUSED	
1.  NO, NOT WORSE AT ANY                  SPECIFIC TIME OF DAY OR NIGHT
2. WORSE WHEN I FIRST WAKE UP
3.  WORSE WHILE AT WORK  
4.  WORSE AFTER LEAVING WORK
5.  WORSE WHILE LYING IN BED 
77.  NA
88.  DON’T KNOW
99.  REFUSED	

Do/did your symptoms get better when you are/were off or work on the weekend or vacation?	
1.  NO
2.  YES
77. NA
88.  DON’T KNOW
99.  REFUSED	
1.  NO
2.  YES
77. NA
88.  DON’T KNOW
99.  REFUSED	
1.  NO
2.  YES
77. NA
88.  DON’T KNOW
99.  REFUSED	
1.  NO
2.  YES
77. NA
88.  DON’T KNOW
99.  REFUSED	

Now, I have a few questions about cigarette smoking.

15.  Have you ever smoked more than 100 cigarettes during your life?
1.  NO (GO TO QUESTION 16)
2.  YES
88.  DON’T KNOW
99.  REFUSED

15a. During the time you smoked, how many packs of cigarettes did you smoke each day?
1. < PACK
2. 1 PACK
3.  1  PACKS
4. >1   PACKS
77.  NA
88.  DON’T KNOW
99.  REFUSED

15b. For how many years did you smoke?	_____ YEARS
77.  NA
88.  DON’T KNOW
99.  REFUSED

15c. Do you smoke now?			1.  NO (GO TO QUESTION 15c1)
2.  YES (GO TO QUESTION 15d)
77.  NA
88.  DON’T KNOW
99.  REFUSED

15c1.  About how many years ago did you quit?

____________ YEARS
77. NA
88. DON’T KNOW
99. REFUSED

GO TO QUESTION 16

15d.  Did you smoke in the last month?	1.   NO 
2.  YES
77.  NA
88.  DON’T KNOW
99.  REFUSED

15e.  Do you smoke some days or every day?
1.  SOME DAYS
2.  EVERY DAY

77.  NA
88.  DON’T KNOW
99.  REFUSED

15f.  About how many cigarettes do you smoke each day?
__________ NUMBER OF CIGARETTES
77.  NA
88.  DON’T KNOW
99.  REFUSED

Now, I just have a few more questions about other illnesses that may affect your lungs.

Have you ever had?  	OR	Do you now have?

Hay fever			16a	1.  NO 			16b	1.  NO
2.  YES				2.  YES
88.  DON’T KNOW			88.  DON’T KNOW
99.  REFUSED			99.  REFUSED

Allergies			17a	1.  NO 			17b	1.  NO
2.  YES				2.  YES
                                                            	Specify				Specify
________________			_______________
________________			_______________
________________			_______________

88.  DON’T KNOW			88.  DON’T KNOW
99.  REFUSED			99.  REFUSED	

Emphsema			18a	1.  NO 			18b	1.  NO
2.  YES				2.  YES
88.  DON’T KNOW			88.  DON’T KNOW
99.  REFUSED			99.  REFUSED

Tuberculosis			19a	1.  NO 			19b	1.  NO
2.  YES				2.  YES
88.  DON’T KNOW			88.  DON’T KNOW
99.  REFUSED			99.  REFUSED

Bronchitis			20a	1.  NO 			20b	1.  NO
2.  YES				2.  YES
88.  DON’T KNOW			88.  DON’T KNOW
99.  REFUSED			99.  REFUSED	

Sinus problems		21a	1.  NO 			21b	1.  NO

2.  YES				2.  YES
88.  DON’T KNOW			88.  DON’T KNOW
99.  REFUSED			99.  REFUSED	

Other				22a.	1.  NO			22b.	1. NO
2.  YES				2. YES
  Specify				  Specify
 _____________________		 _____________________
88.  DON’T KNOW			88. DON’T KNOW
99.  REFUSED			99. REFUSED

Now, just a couple of questions about your general health:

23.	In the past year, did you have to go to the hospital because you had breathing problems or because there was any other problem with your chest or lungs (including trouble catching your breath, wheezing, etc.)?				1.   NO (end interview)
							2.   Yes (go to question 23a)
							77.  NA
							88…DON’T KNOW
							99.  REFUSED

For each of the times you went to the hospital, can you tell me why you went and when?

23a. Why did you go to the hospital (FIRST TIME)?
1. ASTHMA ATTACK
2. TROUBLE BREATHING
3. CHEST TIGHTNESS
4. WHEEZING
5. HEART ATTACK
6. OTHER
Specify ______________________
_____________________________
_____________________________
77. NA
88. DON’T KNOW
99. REFUSED

23a1.  When did you go to the hospital (FIRST TIME)?
______/______
   mm	   yyyy
77. NA
88.  DON’T KNOW
99. REFUSED

23b. Why did you go to the hospital (SECOND TIME)?
1. ASTHMA ATTACK
2. TROUBLE BREATHING
3. CHEST TIGHTNESS
4. WHEEZING
5. HEART ATTACK
6. OTHER
Specify ______________________
_____________________________
_____________________________
77. NA
88. DON’T KNOW
99. REFUSED

23b1.  When did you go to the hospital (SECOND TIME)?
______/______
mm	 yyyy
77. NA
88.  DON’T KNOW
99. REFUSED

23c. Why did you go to the hospital (THIRD TIME)?
1. ASTHMA ATTACK
2. TROUBLE BREATHING
3. CHEST TIGHTNESS
4. WHEEZING
5. HEART ATTACK
6. OTHER
Specify ______________________
_____________________________
_____________________________
77. NA
88. DON’T KNOW
99. REFUSED

23c1.  When did you go to the hospital (THIRD TIME)?
______/______
 mm	 yyyy
77. NA
88.  DON’T KNOW
99. REFUSED