Respondent sequence number
Breathing problem require oxygen?
Problem taking deep breath?
Have a current painful ear infection?
Have you/Has SP ever had eye surgery?
Eye surgery in the last 3 months?
Ever had open chest/abdominal surgery?
Chest/abdominal surgery last 3 months?
Tuberculosis in last year?
Ever told had an aneurysm?
Ever told had a collapsed lung?
Ever told had a detached retina?
Ever told had a stroke?
Ever told had a heart attack?
Stroke in the last 3 months?
Heart attack in last 3 months?
Coughed up blood past month?
Had respiratory illness?
Spirometry First Test Status
Spirometry First Test Comment
Baseline FVC (mL)
Baseline Extrapolated Volume (mL)
Baseline FEV 0.5 (mL)
Baseline FEV 0.75 (mL)
Baseline FEV 1 (mL)
Baseline FEV 3 (mL)
Baseline FEV 6 (mL)
Baseline PEF (mL/s)
Baseline FEF 25-75% (mL/s)
Baseline Forced Expiratory Time (s)
Baseline FVC Quality Attribute
Baseline FEV1 Quality Attribute
Baseline Number of Acceptable Curves
Baseline Effort Quality Attribute
Selected for Bronchodilator
Spirometry Second Test Status
Spirometry Second Test Comment
2nd Test FVC (mL)
2nd Test Extrapolated Volume (mL)
2nd Test FEV 0.5 (mL)
2nd Test FEV 0.75 (mL)
2nd Test FEV 1 (mL)
2nd Test FEV 3 (mL)
2nd Test FEV 6 (mL)
2nd Test PEF (mL/s)
2nd Test FEF 25-75% (mL/s)
2nd Test Forced Expiratory Time (s)
2nd Test FVC Quality Attribute
2nd Test FEV1 Quality Attribute
2nd Test Number of Acceptable Curves
2nd Test Effort Quality Attribute