20A. During the past 3 years, have you had
any chest illnesses that have kept
you off work, indoors at home, or in
1. Yes________________________________
2. No_________________________________
B. Did you produce phlegm with any of
1. Yes________________________________
2. No_________________________________
3. Does not apply_____________________
C. In the last 3 years, how many such
illnesses with (increased) phlegm
did you have which lasted a week or
Number of illnesses___________________
No such illnesses_____________________
21. Did you have any lung trouble before
1. Yes________________________________
2. No_________________________________
22. Have you ever had any of the following?
1A. Attacks of bronchitis?
1. Yes________________________________
2. No_________________________________
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________________________
1. Yes________________________________
2. No_________________________________
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 _______________________
1. Yes________________________________
2. No_________________________________
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________________________
23A. Have you ever had chronic bronchitis?
1. Yes________________________________
2. No_________________________________
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 emphysema?
1. Yes________________________________
2. No_________________________________
1. Yes________________________________
2. No_________________________________
3. Does not apply_____________________
C. Was it confirmed by a doctor?
1. Yes________________________________
2. No_________________________________
3. Does not apply_____________________
At what age did it start?
Age in years__________________________
Does not apply _______________________
25A. Have you ever had asthma?
1. Yes________________________________
2. No_________________________________
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 stopped___________________________
Does not apply________________________
A. Any other chest illness?
1. Yes________________________________
2. No_________________________________
If yes, please specify________________
______________________________________
1. Yes________________________________
2. No ________________________________
If yes, please specify________________
______________________________________
1. Yes _______________________________
2. No ________________________________
If yes, please specify________________
______________________________________
27A. Has a doctor ever told you that you
1. Yes _______________________________
2. No ________________________________
B. Have you ever had treatment for
heart trouble in the past 10 years?
1. Yes________________________________
2. No_________________________________
3. Does not apply_____________________
28A. Has a doctor ever told you that you
1. Yes _______________________________
2. No ________________________________
B. Have you ever had treatment for
high blood pressure (hypertension)
1. Yes _______________________________
2. No ________________________________
3. Does not apply ____________________
29. When did you last have your chest
30. Where did you last have your chest X-rayed (if known)?
______________________________________________________
______________________________________________________
31. Were either of your natural parents ever told by a
doctor that they had a chronic lung condition such as:
FATHER - 1. Yes _____ 2. No _____ 3. Don't Know _____
MOTHER - 1. Yes _____ 2. No _____ 3. Don't Know _____
FATHER - 1. Yes _____ 2. No _____ 3. Don't Know _____
MOTHER - 1. Yes _____ 2. No _____ 3. Don't Know _____
FATHER - 1. Yes _____ 2. No _____ 3. Don't Know _____
MOTHER - 1. Yes _____ 2. No _____ 3. Don't Know _____
FATHER - 1. Yes _____ 2. No _____ 3. Don't Know _____
MOTHER - 1. Yes _____ 2. No _____ 3. Don't Know _____
E. Other chest conditions?
FATHER - 1. Yes _____ 2. No _____ 3. Don't Know _____
MOTHER - 1. Yes _____ 2. No _____ 3. Don't Know _____
F. Is parent currently alive?
FATHER - 1. Yes _____ 2. No _____ 3. Don't Know _____
MOTHER - 1. Yes _____ 2. No _____ 3. Don't Know _____
FATHER - __________ Age if Living
MOTHER - __________ Age if Living
Please specify cause of death
FATHER - _____________________
MOTHER - _____________________
32A. Do you usually have a cough?
(Count a cough with first
smoke or on first going out
of doors. Exclude clearing
of throat.) [If no, skip to
1. Yes _______________________
2. No ________________________
B. Do you usually cough as much
as 4 to 6 times a day 4 or
more days out of the week?
1. Yes _______________________
2. No ________________________
C. Do you usually cough at all on
getting up or first thing in
1. Yes _______________________
2. No ________________________
D. Do you usually cough at all
during the rest of the day or
1. Yes _______________________
2. No ________________________
IF YES TO ANY OF ABOVE (32A, 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 days for 3 consecutive
months or more during the year?
1. Yes _______________________
2. No ________________________
3. Does not apply ____________
F. For how many years have you
Number of Years ______________
Does not apply _______________
33A. Do you usually bring up phlegm
from your chest? (Count phlegm
with the first smoke or on
first going out of doors.
Exclude phlegm from the nose.
1. Yes _______________________
2. No ________________________
B. Do you usually bring up phlegm
like this as much as twice a
day 4 or more days out of the
1. Yes _______________________
2. No ________________________
C. Do you usually bring up phlegm
at all on getting up or first
1. Yes _______________________
2. No ________________________
D. Do you usually bring up phlegm
at all during the rest of the
1. Yes _______________________
2. No ________________________
IF YES TO ANY OF THE ABOVE (33A, B, C, OR D), ANSWER THE FOLLOWING:
IF NO TO ALL, CHECK DOES NOT APPLY AND SKIP TO 34A.
E. Do you bring up phlegm like
consecutive months or more
1. Yes _______________________
2. No ________________________
3. Does not apply ____________
F. For how many years have you
Number of years ______________
Does not apply _______________
EPISODES OF COUGH AND PHLEGM
34A. Have you had periods or
episodes of (increased*) cough
and phlegm and lasting for 3
3 weeks or more each year?
*(For persons who usually
have cough and/or phlegm)
1. Yes _______________________
2. No ________________________
B. For how long have you had at
least 1 such episode per year?
Number of Years ______________
Does not apply _______________