Screening Breathing

Name *

Contact Number *

Email Address *

Date of Birth *

Do You have already breathing disorders such as wheezing, asthma or other disorder? Give detail with how long you have this problem? *

1. Do you have shortness of breath while taking care of your basic needs, such as bathing, showering, eating, or dressing ? *

2. Do you have shortness of breath while Walking ? *

3. Do you have shortness of breath while Performing chores, such as housework, shopping or grocery shopping ? *

4. Do you have shortness of breath while Participating in social activities, such as meeting with family, friends ? *

5. How much of the time have you felt frustrated or impatient? *

6. How much of the time did you feel upset, worried, or depressed? *

7. How much of the time did you feel relaxed and free of tension? *

8. How much of the time have you felt discouraged or down in the dumps? *

9. How happy, satisfied, or pleased have you been with your personal life? *

10. How often have you felt restless, tense, or uptight? *

11. How often did you have a feeling of fear or panic when you had difficulty getting your breath? *

12. How much of the time did you feel very confident and sure that you could deal with your respiratory problem? *

13. How often did you feel upset or scared when you had difficulty getting your breath? *

14. How tired have you felt? *

15. How much energy have you had? *

16. How often have you felt low in energy? *

17. How often have you felt worn out or sluggish? *

18. I’m afraid that I might make my disease worse if I exercise *

19. If I were to try to overcome it, my shortness of breath would increase *

20. Whenever I feel short of breath my body is telling me I have something seriously wrong *

21. My shortness of breath would probably be better if I were to exercise more *

22. People aren’t taking my shortness of breath seriously enough *

23. My lung disease has put my body at risk for the rest of my life *

24. Shortness of breath always means that I’m not getting enough oxygen *

25. Just because doing something makes my shortness of breath worse does not mean that it is dangerous *

26. I am afraid that I may accidentally hurt myself *

27. The best thing I can do to control my shortness of breath is to avoid unnecessary activity *

28. I wouldn’t have as much shortness of breath if there weren’t something potentially dangerous going on in my body *

29. Although my disease causes me to have shortness of breath, I would be better off if I were more physically active *

30. Feeling short of breath lets me know when to stop exercising so that I don’t make myself worse *

31. It’s really not safe for a person with a condition like mine to be physically active *

32. I can’t do most of the things healthy people do because I have to protect my health *

33. Even though doing something is causing me severe shortness of breath, I don’t think it’s actually dangerous *

34. No one should have to exercise when he/she is feeling short of breath *

Chronic Respiratory Disease Questionnaire (CRQ-SAS) - Dyspnea Out of 12

Chronic Respiratory Disease Questionnaire (CRQ-SAS) - EMOTIONAL FUNCTIONING Out of 18

Chronic Respiratory Disease Questionnaire (CRQ-SAS) - DISEASE CONTROL Out of 9

Chronic Respiratory Disease Questionnaire (CRQ-SAS) - FATIGUE Out of 12

Breathlessness Beliefs Questionnaire - Steven De Peuter; Thomas Janssens; Ilse Van Diest; Linda Stans Out of 85

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