| UCAP-Q 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/was the average number of cigarette packs that you smoked each day?
(e.g. 40 cigarettes each day = 2.0 packs/day; 20 cigarettes each day= 1.0 packs/day; 10 cigarettes each day =0.5 packs/day)
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(# packs per day) |
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If Yes, what is the number of years you spent smoking.
(add up all the time you spent smoking)
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(# 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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After you have answered the 13 questions, please press the CALCULATE button to calculate your risk of asthma or COPD.
The information you have entered will be stored on the web server and database of the Ottawa Methods Centre (Ottawa Hospital)
where the researchers can view the responses.
However, your data is anonymous, we will not know your name or your contact information unless you agree to enter the study and
provide this information to us.
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