Human Respiration Assessment
Please complete this assessment to help us evaluate your respiratory health. All information will be kept confidential.
Full Name
*
First Name
Last Name
Age
*
Gender
*
Male
Female
Other
Do you currently have any of the following symptoms? (Select all that apply)
*
Cough
Shortness of breath
Wheezing
Chest pain or tightness
None of the above
Other
Please rate the severity of the following symptoms over the past week:
*
Rows
None
Mild
Moderate
Severe
Cough
1
2
3
4
Shortness of breath
5
6
7
8
Wheezing
9
10
11
12
Chest pain or tightness
13
14
15
16
Do you have a history of any of the following respiratory conditions?
*
Asthma
Chronic bronchitis
Emphysema
Pneumonia
Allergies (respiratory)
None
Other
Do you smoke?
*
Never smoked
Former smoker
Current smoker
Are you regularly exposed to any of the following environmental factors? (Select all that apply)
*
Dust
Fumes/chemicals
Pollen
Animal dander
None of the above
Other
How would you rate your current level of physical activity?
*
Very low
1
2
3
4
Very high
5
1 is Very low, 5 is Very high
Is there anything else you would like to share regarding your respiratory health?
Submit Assessment
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