Respiratory Quality of Life Assessment Form
Please complete the Respiratory Quality of Life Assessment Form to help us understand how your breathing affects your daily life.
How often do you experience shortness of breath during daily activities?
*
Never
Rarely
Sometimes
Often
Always
Rate the severity of your cough over the past week.
*
1
2
3
4
5
In the past 7 days, how much have respiratory symptoms interfered with your sleep?
*
Not at all
A little
Moderately
Quite a bit
Extremely
How limited do you feel in performing physical activities due to your breathing?
*
Not limited
1
2
3
4
Completely limited
5
1 is Not limited, 5 is Completely limited
How often do you avoid social activities because of your respiratory symptoms?
*
Never
Rarely
Sometimes
Often
Always
Please indicate how much you agree with the following statements about your respiratory health.
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I feel confident managing my respiratory symptoms
1
2
3
4
5
I worry about my breathing getting worse
6
7
8
9
10
I feel supported by those around me
11
12
13
14
15
How much do you feel your respiratory condition affects your emotional well-being?
*
Not at all
1
2
3
4
A great deal
5
1 is Not at all, 5 is A great deal
During the past week, how would you rate your overall respiratory health?
*
1
2
3
4
5
How often do you need to use inhalers or breathing treatments?
*
Never
Once a week or less
A few times a week
Daily
Multiple times a day
Please share any additional comments about how your breathing affects your quality of life.
Submit Assessment
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