123456789101112131415161718192021 Your Name First Last Your Email Address* We will not share this information with any 3rd parties.Your Physician's NameHospital/Practice Name 1a. How often do you walk up and down stairs (8 - 12 steps)? Never Rarely Sometimes Frequently 1b. Do you avoid stairs because it makes you tired or short of breath? Yes No 1c. How often do you get short of breath or tired when you walk up and down a flight of stairs at a normal pace under normal conditions? Never Rarely Sometimes Frequently 1d. How often do you get short of breath or tired when you walk up and down a flight of stairs quickly? Never Rarely Sometimes Frequently 2a. How often do you engage in strenuous work or prolonged exertion at work or play? Never Rarely Sometimes Frequently 2b. Do you think you would get short of breath or tired if you engaged in these activities? Yes No 2c. How often do you get short of breath or tired doing strenuous work of prolonged exertion? Never Rarely Sometimes Frequently 3a. How often do you go for walks, either outside or inside, on level ground at a normal pace under normal conditions? Never Rarely Sometimes Frequently 3b. Do you avoid walks because it will make you short of breath or tired? Yes No 3c. How often would you get short of breath or tired if you walked less than 1 block? Never Rarely Sometimes Frequently 3d. How often would you get short of breath or tired if you walked more than 2 blocks? Never Rarely Sometimes Frequently 3e. How often do you find yourself walking more slowly than usual? Never Rarely Sometimes Frequently 4. How often do you get short of breath or tired when you are sitting doing nothing or when you are sleeping? Never Rarely Sometimes Frequently 5a. How often do you walk up hills? Never Rarely Sometimes Frequently 5b. Do you avoid walking up hills because it makes you short of breath or tired? Yes No 5c. How often do you get short of breath or tired walking up hills in normal weather? Never Rarely Sometimes Frequently 6a. How often do you go out in the cold/windy or hot/humid weather? Never Rarely Sometimes Frequently 6b. Do you avoid cold/windy or hot/humid weather because it makes you short of breath or tired? Yes No 6c. How often do you get short of breath or tired when you go outside in the cold/windy or hot/humid weather? Never Rarely Sometimes Frequently 7a. On a scale of 1 -10, with 10 being perfectly normal and 1 being near death, how would you rate yourself? 1 2 3 4 5 6 7 8 9 10 Δ
