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Breath
Your Name
*
Name of the Doctor Referring / Adminsitering
Contact Number
*
Contact Number of the Doctor Referring / Adminsitering
Email Address
*
Date of Birth of the Person
*
For each activity listed below, please rate your breathlessness on a scale between NOT AT ALL and MAXIMALLY BREATHLESS or TOO BREATHLESS to do the activity. If the activity one which you do not perform, please give your best estimate of breathlessness. Your response should be for an 'Average Day" during the past week. Please respond to all items.
1. How short of breath do you get at REST
*
Not at all Breathless
Very Slightly Breathless
Somewhat Breathless
Considerably Breathless
Severly Breathless
Maximally or unable to do because of breathlessness
2. How short of breath walking on a level at your own pace
*
Not at all Breathless
Very Slightly Breathless
Somewhat Breathless
Considerably Breathless
Severly Breathless
Maximally or unable to do because of breathlessness
3. How short of breath Walking with others of your age
*
Not at all Breathless
Very Slightly Breathless
Somewhat Breathless
Considerably Breathless
Severly Breathless
Maximally or unable to do because of breathlessness
4. How short of breath Walking Up a hill
*
Not at all Breathless
Very Slightly Breathless
Somewhat Breathless
Considerably Breathless
Severly Breathless
Maximally or unable to do because of breathlessness
5. How short of breath Walking Up Stairs
*
Not at all Breathless
Very Slightly Breathless
Somewhat Breathless
Considerably Breathless
Severly Breathless
Maximally or unable to do because of breathlessness
6. How short of breath While eating
*
Not at all Breathless
Very Slightly Breathless
Somewhat Breathless
Considerably Breathless
Severly Breathless
Maximally or unable to do because of breathlessness
7. How short of breath Standing Up from a Chair
*
Not at all Breathless
Very Slightly Breathless
Somewhat Breathless
Considerably Breathless
Severly Breathless
Maximally or unable to do because of breathlessness
8. How short of breath Brushing teeth
*
Not at all Breathless
Very Slightly Breathless
Somewhat Breathless
Considerably Breathless
Severly Breathless
Maximally or unable to do because of breathlessness
9. How short of breath While Shaving and or Brushing Hair
*
Not at all Breathless
Very Slightly Breathless
Somewhat Breathless
Considerably Breathless
Severly Breathless
Maximally or unable to do because of breathlessness
10. How short of breath While Showering / Bathing
*
Not at all Breathless
Very Slightly Breathless
Somewhat Breathless
Considerably Breathless
Severly Breathless
Maximally or unable to do because of breathlessness
11. How short of breath While Dressing
*
Not at all Breathless
Very Slightly Breathless
Somewhat Breathless
Considerably Breathless
Severly Breathless
Maximally or unable to do because of breathlessness
12. How short of breath While Picking Up and Straightening
*
Not at all Breathless
Very Slightly Breathless
Somewhat Breathless
Considerably Breathless
Severly Breathless
Maximally or unable to do because of breathlessness
13. How short of breath While Doing Dishes
*
Not at all Breathless
Very Slightly Breathless
Somewhat Breathless
Considerably Breathless
Severly Breathless
Maximally or unable to do because of breathlessness
14. How short of breath While Sweeping and Vaccuming
*
Not at all Breathless
Very Slightly Breathless
Somewhat Breathless
Considerably Breathless
Severly Breathless
Maximally or unable to do because of breathlessness
15. How short of breath While Making Bed
*
Not at all Breathless
Very Slightly Breathless
Somewhat Breathless
Considerably Breathless
Severly Breathless
Maximally or unable to do because of breathlessness
16. How short of breath While Shopping
*
Not at all Breathless
Very Slightly Breathless
Somewhat Breathless
Considerably Breathless
Severly Breathless
Maximally or unable to do because of breathlessness
17. How short of breath While Doing Laundry
*
Not at all Breathless
Very Slightly Breathless
Somewhat Breathless
Considerably Breathless
Severly Breathless
Maximally or unable to do because of breathlessness
18. How short of breath While Washing Car
*
Not at all Breathless
Very Slightly Breathless
Somewhat Breathless
Considerably Breathless
Severly Breathless
Maximally or unable to do because of breathlessness
19. How short of breath While Mowing Lawn
*
Not at all Breathless
Very Slightly Breathless
Somewhat Breathless
Considerably Breathless
Severly Breathless
Maximally or unable to do because of breathlessness
20. How short of breath While Watering Lawn
*
Not at all Breathless
Very Slightly Breathless
Somewhat Breathless
Considerably Breathless
Severly Breathless
Maximally or unable to do because of breathlessness
20. How short of breath in sexual activities
*
Not at all Breathless
Very Slightly Breathless
Somewhat Breathless
Considerably Breathless
Severly Breathless
Maximally or unable to do because of breathlessness
21. How much do these limit you in your daily life? - SHORTNESS OF BREATH
*
Not at all Breathless
Very Slightly Breathless
Somewhat Breathless
Considerably Breathless
Severly Breathless
Maximally or unable to do because of breathlessness
22. How much do these limit you in your daily life? - FEAR OF HURTING YOURSELF BY OVEREXERTING
*
Not at all Breathless
Very Slightly Breathless
Somewhat Breathless
Considerably Breathless
Severly Breathless
Maximally or unable to do because of breathlessness
23. How much do these limit you in your daily life? - FEAR OF SHORTNESS OF BREATH
*
Not at all Breathless
Very Slightly Breathless
Somewhat Breathless
Considerably Breathless
Severly Breathless
Maximally or unable to do because of breathlessness
New Dyspnea Measure The UCSD Shortness of Breath Questionnaire Eaking et al 1998 - Out of 120
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