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Asthma Quality of Life Questionnaire(s)
Please complete all questions by circling the number that best describes how you have been during the last 2 weeks as a result of your asthma.

HOW LIMITED HAVE YOU BEEN DURING THE LAST 2 WEEKS IN THESE ACTIVITIES AS A RESULT OF YOUR ASTHMA?

  Totally Limited Extremely Limited Very Limited Moderate Limitation Some Limitation A Little Limitation Not at all Limited
1. STRENUOUS ACTIVITIES
(such as hurrying, exercising, running up stairs, sports)
  1   2   3   4   5   6   7 *
2. MODERATE ACTIVITIES
(such as walking, housework, gardening, shopping, climbing stairs)
  1   2   3   4   5   6   7 *
3. SOCIAL ACTIVITIES
(such as talking, playing with pets/children, visiting friends/relatives)
  1   2   3   4   5   6   7 *
4. WORK/SCHOOL-RELATED ACTIVITIES*
(tasks you have to do at work/in school)
  1   2   3   4   5   6   7 *
5. SLEEPING   1   2   3   4   5   6   7 *

*If you are not employed or self-employed, these should be tasks you have to do most days.


HOW MUCH DISCOMFORT OR DISTRESS HAVE YOU FELT DURING THE LAST 2 WEEKS?

  A Very Great Deal A Great Deal A Good Deal Moderate Amount Some Very little None
6. How much discomfort or distress have you felt over the last 2 weeks as a result of CHEST TIGHTNESS?   1   2   3   4   5   6   7 *

IN GENERAL HOW MUCH OF THE TIME DURING THE LAST 2 WEEKS DID YOU:

  All of the Time Most of the Time A Good Bit of the Time Some of the Time A Little of the Time Hardly Any of the Time None of the Time
7. Feel CONCERNED ABOUT HAVING ASTHMA?   1   2   3   4   5   6   7 *
8. Feel SHORT OF BREATH as a result of your asthma?   1   2   3   4   5   6   7 *
9. Experience asthma symptoms as a RESULT OF BEING EXPOSED TO CIGARETTE SMOKE?   1   2   3   4   5   6   7 *
10. Experience a WHEEZE in your chest?   1   2   3   4   5   6   7 *
11. Feel you had to AVOID A SITUATION OR ENVIRONMENT BECAUSE OF CIGARETTE SMOKE?   1   2   3   4   5   6   7 *

HOW MUCH DISCOMFORT OR DISTRESS HAVE YOU FELT DURING THE LAST 2 WEEKS?

  A Very Great Deal A Great Deal A Good Deal Moderate Amount Some Very little None
12. How much discomfort or distress have you felt over the last 2 weeks as a result of COUGHING?   1   2   3   4   5   6   7 *

IN GENERAL, HOW MUCH OF THE TIME DURING THE LAST 2 WEEKS DID YOU:

  All of the Time Most of the Time A Good Bit of the Time Some of the Time A Little of the Time Hardly Any of the Time None of the Time
13. Feel FRUSTRATED as a result of your asthma?   1   2   3   4   5   6   7 *
14. Experience a feeling of CHEST HEAVINESS?   1   2   3   4   5   6   7 *
15. Feel CONCERNED ABOUT THE NEED TO USE MEDICATION for your asthma?   1   2   3   4   5   6   7 *
16. Feel the need to CLEAR YOUR THROAT?   1   2   3   4   5   6   7 *
17. Experience asthma symptoms as a RESULT OF BEING EXPOSED TO DUST?   1   2   3   4   5   6   7 *
18. Experience DIFFICULTY BREATHING OUT as a result of your asthma?   1   2   3   4   5   6   7 *
19. Feel you had to AVOID A SITUATION OR ENVIRONMENT BECAUSE OF DUST?   1   2   3   4   5   6   7 *
20. WAKE UP IN THE MORNING WITH ASTHMA SYMPTOMS?   1   2   3   4   5   6   7 *
21. Feel AFRAID OF NOT HAVING YOUR ASTHMA MEDICATION AVAILABLE?   1   2   3   4   5   6   7 *
22. Feel bothered by HEAVY BREATHING?   1   2   3   4   5   6   7 *
23. Experience asthma symptoms as a RESULT OF THE WEATHER OR AIR POLLUTION OUTSIDE?   1   2   3   4   5   6   7 *
24. Were you WOKEN AT NIGHT by your asthma?   1   2   3   4   5   6   7 *
25. AVOID OR LIMIT GOING OUTSIDE BECAUSE OF THE WEATHER OR AIR POLLUTION?   1   2   3   4   5   6   7 *
26. Experience asthma symptoms as a RESULT OF BEING EXPOSED TO STRONG SMELLS OR PERFUME?   1   2   3   4   5   6   7 *
27. Feel AFRAID OF GETTING OUT OF BREATH?   1   2   3   4   5   6   7 *
28. Feel you had to AVOID A SITUATION OR ENVIRONMENT BECAUSE OF STRONG SMELLS OR PERFUME?   1   2   3   4   5   6   7 *
29. Has your asthma INTERFERED WITH GETTING A GOOD NIGHT'S SLEEP?   1   2   3   4   5   6   7 *
30. Have a feeling of FIGHTING FOR AIR?   1   2   3   4   5   6   7 *


HOW LIMITED HAVE YOU BEEN DURING THE LAST 2 WEEKS?

  Severly Limited Most Not Done Very Limited Moderately Limited Several Not Done Slightly Limited Very Slightly Limited Very Few Not Done Hardly Limited at All Not Limited Have Done All Activities
31. Think of the OVERALL RANGE OF ACTIVITIES that you would have liked to have done during the last 2 weeks. How much has your range of activities been limited by your asthma?   1   2   3   4   5   6   7 *


HOW LIMITED HAVE YOU BEEN DURING THE LAST 2 WEEKS?

  Totally Limited Extremely Limited Very Limited Moderate Limitation Some Limitation A Little Limitation Not at all Limited
32. Overall, among ALL THE ACTIVITIES that you have done during the last 2 weeks, how limited have you been by your asthma?   1   2   3   4   5   6   7 *