| UCAP Questionnaire |
| 1
| How old are you? |
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| 2
| Are you currently smoking cigarettes or have you smoked cigarettes in the past? |
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If Yes, what is the average number of cigarette packs per day |
(# packs per day) |
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If Yes, what is the number of years you have spent smoking |
(# years)
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(pack years)
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| 3 |
Are you regularly exposed to cigarette smoke on a daily basis (either from yourself, or from people around you)? |
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| 4a |
Have you ever worked for 3 months or more with paint, chemicals, or fumes? |
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If Yes, how many months did you work? |
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| 4b |
Have you ever worked for 3 months or more with sandblasting? |
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If Yes, how many months did you work? |
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| 5 |
Are you currently taking the medication Salbutamol (also known as Ventolin) for your breathing? |
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| 6 |
If you have a wheeze, is it worse in the morning? |
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| 7 |
During the past 3 months, how many severe or very unpleasant attacks of chest problems (attacks of shortness of breath or wheezing) have you had? |
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| 8 |
Please rate your cough on a scale of 0 to 5 with 0 meaning I never cough to 5 meaning I cough all the time
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| 9 |
Please rate your sleep on a scale of 0 to 5 with 0 meaning I sleep soundly to 5 meaning I do not sleep soundly because of my lung condition? |
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| 10 |
Please rate your chest tightness on a scale of 0 to 5 with 0 meaning no chest tightness at all to 5 meaning my chest feels very tight
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| 11 |
Does your health now limit you in vigorous activities, such as running, lifting heavy objects, or participating in strenuous sports? |
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| 12 |
How much of the time during the past 4 weeks, did you feel tired? |
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| 13 |
During the past 4 weeks, how much of the time have you had to cut down on the amount of time you spent on work or other regular activities as a result of any emotional problems, such as feeling depressed or anxious? |
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| Telephone No.:
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| UCAP Questionnaire Asthma Risk Score:
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| UCAP Questionnaire COPD Risk Score:
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