WRNMMC Pulmonary Exercise Questionnaire
IMPORTANT: Click panel header to expand/collapse questionnaire in each panel. ***All FIELDS ARE REQUIRED.***
Demographics
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Last Name:
Age (16-100):
Gender:
F
M
Occupation:
Exercise Date:
Past Medical History
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Have you been diagnosed with (
check all that apply
):
1) A breathing condition:
asthma
COPD
COVID-19 Infection
interstitial lung disease
none
other
If other, please explain:
2) A heart condition:
heart failure
heart valve disease
abnormal heart rhythm
high blood pressure
coronary artery disease
heart attack
none
other
If other, please explain:
3) A neurologic condition:
ALS
myasthenia gravis
multiple sclerosis (MS)
Parkinson’s disease
stroke
traumatic brain injury (TBI)
none
other
If other, please explain:
4) Behavioral Health:
depression
anxiety
PTSD
chronic pain
none
other
If other, please explain:
5) Currently or previously evaluated by behavioral health for a personal or professional issue or concern?
Yes
No
6) Heightened feelings of stress within the past 2-4 weeks:
Yes
No
7) Sleep:
insomnia
sleep apnea
I am a shift worker (work outside of the normal 07:00AM to 17:00PM work day)
I sleep 6 hours per night or less
I sleep 4 hours per night or less
none
other
If other, please explain:
Current Medications
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1) Prescription:
2) Inhalers:
3) Sleep Aids or Sleeping pills
4) Over the Counter (OTC): (including cold medicines, allergy medications, Tylenol, Motrin, and Vitamins/Herbs):
5) Supplements: (includes protein powders, energy drinks, pre-/post-workout supplements, weight loss/gainer formulas):
6) Other:
Nijmegen Questionnaire (NQ)
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Certain breathing disorders cause symptoms outside the chest.
We appreciate your honest assessment in answering the following questions:
Symptom
Never - 0
Rarely – 1
Sometimes – 2
Often – 3
Very Often – 4
Chest Pain:
0
1
2
3
4
Feeling Tense:
0
1
2
3
4
Blurred Vision:
0
1
2
3
4
Dizzy Spells:
0
1
2
3
4
Feeling Confused:
0
1
2
3
4
Faster/Deeper Breathing:
0
1
2
3
4
Short of Breath:
0
1
2
3
4
Tight Feelings in Chest:
0
1
2
3
4
Bloated Feeling in Stomach:
0
1
2
3
4
Tingling Fingers:
0
1
2
3
4
Unable to Breath Deeply:
0
1
2
3
4
Stiff Fingers or Arms:
0
1
2
3
4
Tight Feelings around Mouth:
0
1
2
3
4
Cold Hands or Feet:
0
1
2
3
4
Palpitations:
0
1
2
3
4
Feelings of Anxiety:
0
1
2
3
4
1) Occurrence: Do you notice your symptoms occur in any particular pattern, time of day, or circumstance? (
check all that apply
)
Rest
Exertion
Night
Cold/Weather Change
N/A
Other
If other, please explain:
2) Any known triggers? (
check all that apply
)
Exercise
Stress
High emotional states
Environmental factors
N/A
Other
If other, please explain:
3) If symptoms occur predominantly with exercise, at what point in the engagement of the physical exercise do they occur?
a) Onset (within first 1-2 minutes)
b) During (after first 5-8 minutes)
c) Following (5-10 minutes after completing exercise
d) Intensity-specific: all intensities
e) Intensity-specific: moderate levels of intensity (HR 70-79% of max HR, sustained)
f) Intensity-specific: high levels of intensity (HR> 80% of max HR, sustained)
N/A
Other
If other, please explain:
Exercise Patterns
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1) How many days/week (1-7) do you exercise (with exercise being defined as engaging in a physically rigorous activity for at least 30 minutes or more continuously with the sole purpose of improving either cardiovascular conditioning or muscular strength . **Exercise does NOT include the number of steps walked during the work day as part of normal movement/routine.
2) How many minutes for each session do you average (1-360)?
3) What forms of exercise do you engage in? (
check all that apply
)
a)Aerobic
Walking
Running
Biking
Hiking
Swimming
Elliptical
Rowing/rower
Other
If other, please explain:
b) Strength Training
Weight lifting
Rock climbing
Martial arts
Other
If other, please explain:
c) Core Training
d) Yoga
e) Zumba
f) Cross-fit
g) P90X
h) Insanity
i) Orange Theory
j) Team Sports/ Sports League (recreational soccer, hockey, flag football, basketball, etc)
Other
If other, please explain:
Breathing Patterns
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1) Do you ever notice yourself intermittently taking deep breaths or sighing throughout the day?
Yes
No
2) Do you notice whether you initiate your breath from your chest or your abdomen? (
check all that apply
)
Abdomen
Chest
Both
Neither
Don’t know
3) Do you ever find yourself using your abdominal muscles to help you fully exhale?
Yes
No
4) Do you notice your breathing patterns fluctuate throughout the day or during specific circumstances?
Yes
No
If Yes, check all that apply:
Exercise
Stressful situations
Sleep
Other
If other, please explain: