During the past week, how often did you feel… | |||||||
 | Never | Hardly | A few | Several times | Many times | Most of the time | All the time |
 1. Short of breath at rest? | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
 2. Short of breath doing physical activities? | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
 3. Concerned about your breathing getting worse? | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
 4. Depressed (down) because of your breathing problems? | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
During the past week, how much of the time did you… | |||||||
 5. Cough | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
 6. Produce phlegm? | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
During the past week, how limited were you in these activities because of your breathing problems when doing… | |||||||
 | Not limited at all | Very slightly limited | Slightly limited | Moderately limited | Very limited | Extremely limited | Totally limited or unable to do |
 7. Strenuous physical activities (such as climbing stairs, hurrying, doing sports)? |  |  |  |  |  |  |  |
 8. Moderate physical activities (such as walking, housework, carrying things)? |  |  |  |  |  |  |  |
 9. Daily activities at home (such as dressing, washing yourself)? |  |  |  |  |  |  |  |
 10. Social activities (such as talking, being with children, visiting friends/relatives)? |  |  |  |  |  |  |  |