D. Are you suffering from or have you ever suffered from: YES NO a. Epilepsy (or fits, seizures, convulsions)? b. Rheumatic fever? c. Kidney disease? d. Bladder disease? e. Diabetes? f. Jaundice? 18. CHEST COLDS AND CHEST ILLNESSES 18A. If you get a cold, does it "usually" 1. Yes 2. No   go to your chest? (Usually means more 3. Don't get colds   than 1/2 the time) 19A. During the past 3 years, have you 1. Yes 2. No had any chest illnesses that have kept you off work, indoors at home, or in bed? IF YES TO 19A: B. Did you produce phlegm with any of 1. Yes 2. No   these chest illnesses? 3. Does Not Apply C. In the last 3 years, how many such Number of illnesses illnesses with (increased) phlegm did you No such illnesses   have which lasted a week or more? 20. Did you have any lung trouble before the 1. Yes 2. No   age of 16? 21. Have you ever had any of the following? 1A. Attacks of bronchitis? 1. Yes 2. No IF YES TO 1A:

B. Was it confirmed by a doctor? 1. Yes 2. No 3. Does Not Apply C. At what age was your first attack? Age in Years Does Not Apply 2A. Pneumonia (include bronchopneumonia)? 1. Yes 2. No IF YES TO 2A: B. Was it confirmed by a doctor? 1. Yes 2. No 3. Does Not Apply C. At what age did you first have it? Age in Years Does Not Apply 3A. Hay Fever? 1. Yes 2. No IF YES TO 3A: B. Was it confirmed by a doctor? 1. Yes 2. No 3. Does Not Apply C. At what age did it start? Age in Years Does Not Apply 22A. Have you ever had chronic bronchitis? 1. Yes 2. No IF YES TO 22A: B. Do you still have it? 1. Yes 2. No 3. Does Not Apply C. Was it confirmed by a doctor? 1. Yes 2. No 3. Does Not Apply D. At what age did it start? Age in Years Does Not Apply

23A. Have you ever had emphysema? 1. Yes 2. No IF YES TO 23A: B. Do you still have it? 1. Yes 2. No 3. Does Not Apply C. Was it confirmed by a doctor? 1. Yes 2. No 3. Does Not Apply D. At what age did it start? Age in Years Does Not Apply 24A. Have you ever had asthma? 1. Yes 2. No IF YES TO 24A: B. Do you still have it? 1. Yes 2. No 3. Does Not Apply C. Was it confirmed by a doctor? 1. Yes 2. No 3. Does Not Apply D. At what age did it start? Age in Years Does Not Apply E. If you no longer have it, at what age did it stop? Age stopped Does Not Apply 25. Have you ever had: A. Any other chest illness? 1. Yes 2. No If yes, please specify B. Any chest operations? 1. Yes 2. No If yes, please specify C. Any chest injuries? 1. Yes 2. No If yes, please specify 26A. Has a doctor ever told 1. Yes 2. No

you that you had heart trouble? IF YES TO 26A: B. Have you ever had 1. Yes 2. No treatment for heart 3. Does Not Apply trouble in the past 10 years? 27A. Has a doctor told you 1. Yes 2. No   that you had high blood   pressure? IF YES TO 27A: B. Have you had any 1. Yes 2. No treatment for high 3. Does Not Apply blood pressure (hypertension) in the   past 10 years? 28. When did you last have your chest X-rayed? (Year) 29. Where did you last have your chest X-rayed (if known)? What was the outcome?

FAMILY HISTORY 30. Were either of your natural parents ever told by a doctor that they had a chronic lung condition such as: FATHER MOTHER 1. Yes 2. No 3. Don't 1. Yes 2. No 3. Don't know know A. Chronic Bronchitis? B. Emphysema? C. Asthma? D. Lung cancer? E. Other chest conditions? F. Is parent currently alive? G. Please Specify Age if Living Age if Living Age at Death Age at Death Don't Know Don't Know H. Please specify cause of death COUGH 31A. Do you usually have a cough? (Count a 1. Yes 2. No cough with first smoke or on first going out of doors. Exclude clearing of throat.) (If no, skip to question 31 C.) B. Do you usually cough as much as 4 to 6 1. Yes 2. No times a day 4 or more days out of the week? C. Do you usually cough at all on getting up 1. Yes 2. No or first thing in the morning?

Do you usually cough at all during the 1. Yes 2. No rest of the day or at night? IF YES TO ANY OF ABOVE (31A, B, C, OR D), ANSWER THE FOLLOWING. IF NO TO ALL, CHECK "DOES NOT APPLY" AND SKIP TO NEXT PAGE E. Do you usually cough like this on most 1. Yes 2. No days for 3 consecutive months or more 3. Does not apply during the year?? F. For how many years have you had the Number of years cough? Does not apply 32A. Do you usually bring up phlegm from 1. Yes 2. No your chest? Count phlegm with the first smoke or on first going out of doors. Exclude phlegm from the nose. Count swallowed phlegm.) (If no, skip to 32C) B. Do you usually bring up phlegm like this 1. Yes 2. No as much as twice a day 4 or more days out of the week? C. Do you usually bring up phlegm at all on 1. Yes 2. No getting up or first thing in the morning? D. Do you usually bring up phlegm at all on 1. Yes 2. No during the rest of the day or at night? IF YES TO ANY OF THE ABOVE (32A, B, C, OR D), ANSWER THE FOLLOWING: IF NO TO ALL, CHECK "DOES NOT APPLY" AND SKIP TO 33A E. Do you bring up phlegm like 1. Yes 2. No this on most days for 3 3. Does not apply consecutive months or more during the year? F. For how many years have you Number of years had trouble with phlegm? Does not apply

EPISODES OF COUGH AND PHLEGM 33A. Have you had periods or 1. Yes 2. No episodes of (increased*) cough and phlegm lasting for 3 weeks or more each year? *(For persons who usually have cough and/or phlegm) IF YES TO 33A B. For how long have you had at Number of years least 1 such episode per year? Does not apply WHEEZING 34A. Does your chest ever sound wheezy or whistling 1. When you have a cold? 1. Yes 2. No 2. Occasionally apart from colds? 1. Yes 2. No 3. Most days or nights? 1. Yes 2. No B. For how many years has this Number of years been present? Does not apply 35A. Have you ever had an attack of 1. Yes 2. No wheezing that has made you feel short of breath? IF YES TO 35A B. How old were you when you had your first such attack? Age in years Does not apply C. Have you had 2 or more such episodes? 1. Yes 2. No 3. Does not apply D. Have you ever required medicine or treatment for the(se) attack(s)? 1. Yes 2. No 3. Does not apply

BREATHLESSNESS 36. If disabled from walking by any Nature of condition(s) condition other than heart or lung disease, please describe and proceed to question 38A. 37A. Are you troubled by shortness 1. Yes 2. No of breath when hurrying on the level or walking up a slight hill? IF YES TO 37A B. Do you have to walk slower 1. Yes 2. No than people of your age on the 3. Does not apply level because of breathlessness? C. Do you ever have to stop for 1. Yes 2. No breath when walking at your 3. Does not apply own pace on the level? D. Do you ever have to stop for 1. Yes 2. No breath after walking about 100 3. Does not apply yards (or after a few minutes) on the level? E. Are you too breathless to leave 1. Yes 2. No the house or breathless on 3. Does not apply dressing or climbing one flight of stairs? TOBACCO SMOKING 38A. Have you ever smoked 1. Yes 2. No cigarettes? (No means less than 20 packs of cigarettes or 12 oz. of tobacco in a lifetime or less than 1 cigarette a day for 1 year.) IF YES TO 38A B. Do you now smoke cigarettes 1. Yes 2. No   (as of one month ago) 3. Does not apply

C. How old were you when you Age in years   first started regular cigarette Does not apply smoking? D. If you have stopped smoking Age stopped cigarettes completely, how old Check if still   were you when you stopped? smoking Does not apply E. How many cigarettes do you Cigarettes   smoke per day now? per day   Does not apply F. On the average of the entire Cigarettes time you smoked, how many per day cigarettes did you smoke per Does not apply day? G. Do or did you inhale the 1. Does not apply   cigarette smoke? 2. Not at all   3. Slightly   4. Moderately   5. Deeply 39A. Have you ever smoked a pipe 1. Yes 2. No   regularly? (Yes means more than 12 oz. of   tobacco in a lifetime.) IF YES TO 39A: FOR PERSONS WHO HAVE EVER SMOKED A PIPE B. 1. How old were you when Age you started to smoke a pipe regularly? 2. If you have stopped Age stopped smoking a pipe completely, Check if still smoking pipe how old were you when Does not apply you stopped?

C. On the average over the oz. per week (a standard pouch of entire time you smoked a tobacco contains 1 1/2 oz.) pipe, how much pipe Does not apply tobacco did you smoke per week? D. How much pipe tobacco are oz. per week   you smoking now? Not currently smoking a pipe E. Do you or did you inhale 1. Never smoked   the pipe smoke? 2. Not at all 3. Slightly 4. Moderately 5. Deeply 40A. Have you ever smoked cigars 1. Yes 2. No   regularly? (Yes means more than 1 cigar a week for a year) IF YES TO 40A FOR PERSONS WHO HAVE EVER SMOKED A CIGAR B. 1. How old were you when you Age   started smoking cigars regularly? 2. If you have stopped smoking Age stopped cigars completely, how old were Check if still you when you stopped smoking Does not apply cigars? C. On the average over the entire Cigars per week   time you smoked cigars, how Does not apply many cigars did you smoke per week? D. How many cigars are you Cigars per week   smoking per week now? Check if not smoking cigars currently E. Do or did you inhale the cigar 1. Never smoked smoke? 2. Not at all 3. Slightly 4. Moderately 5. Deeply Signature Date

11F. In the past year, what was your: 1. Job/occupation? 2. Position/job title? 12. RECENT MEDICAL HISTORY 12A. Do you consider yourself to be in good health? Yes No If NO, state reason 12B. In the past year, have you developed: Yes No Epilepsy? Rheumatic fever? Kidney disease? Bladder disease? Diabetes? Jaundice? Cancer? 13. CHEST COLDS AND CHEST ILLNESSES 13A. If you get a cold, does it "usually" go to your chest? (usually means more than 1/2 the time) 1. Yes 2. No 3. Don't get colds 14A. During the past year, have you had any chest illnesses that have kept you 1. Yes 2. No off work, indoors at home, or in bed? 3. Does Not Apply IF YES TO 14A: 14B. Did you produce phlegm with any 1. Yes 2. No of these chest illnesses? 3. Does Not Apply 14C. In the past year, how many such Number of illnesses illnesses with (increased) phlegm No such illnesses did you have which lasted a week or more?

15. RESPIRATORY SYSTEM In the past year have you had: Yes or No Further Comment on Positive Answers Asthma Bronchitis Hay Fever Other Allergies Yes or No Further Comment on Positive Answers Pneumonia Tuberculosis Chest Surgery Other Lung Problems Heart Disease Do you have: Yes or No Further Comment on Positive Answers Frequent colds Chronic cough Shortness of breath when walking or climbing one flight or stairs Do you: Wheeze Cough up phlegm Smoke cigarettes Packs per day How many years Date Signature