Question Title

* 1. Your ID and postal code. 

Question Title

* 2. Please enter today's date.

Date / Time
This is a test that focuses on respiratory health measures.  

Please move the sliders with your mouse as indicated to answer the questions, or type the number in the box on the right.

Do not skip any questions.

Thank you!

Question Title

* 3. On a scale of 0 to 5, please indicate your current situation:
0 = I never cough              
5 = I cough all the time

0 On a scale of 0 to 5, indicate your current situation 5
i We adjusted the number you entered based on the slider’s scale.

Question Title

* 4. On a scale of 0 to 5, please indicate your current situation:
0=I have no phlegm (mucus) in my chest at all
5= My chest is completely full of phlegm (mucus)

0 On a scale of 0 to 5, indicate your current situation 5
i We adjusted the number you entered based on the slider’s scale.

Question Title

* 5. On a scale of 0 to 5, please indicate your current situation:
0 = When I walk up a hill or one flight of stairs, I am not breathless.
5 = When I walk up a hill or one flight of stairs, I am very breathless. 

0 On a scale of 0 to 5,indicate your current situation 5
i We adjusted the number you entered based on the slider’s scale.

Question Title

* 6. On a scale of 0 to 5, please indicate your current situation:
0 = My chest does not feel tight at all
5 = My chest feels very tight

0 On a scale of 0 to 5, indicate your current situation 5
i We adjusted the number you entered based on the slider’s scale.

Question Title

* 7. On a scale of 0 to 5, please indicate your current situation:
0 = I am not limited doing any activities at home
5 = I am very limited doing activities at home

0 On a scale of 0 to 5,indicate your current situation 5
i We adjusted the number you entered based on the slider’s scale.

Question Title

* 8. On a scale of 0 to 5, please indicate your current situation:
0 = I am confident leaving my home despite any current physical condition
5 = I am not at all confident leaving my house because of a physical condition

0 On a scale of 0 to 5, indicate your current situation 5
i We adjusted the number you entered based on the slider’s scale.

Question Title

* 9. On a scale of 0 to 5, please indicate your current situation:
0 = I sleep soundly
5 = I don't sleep soundly

0 On a scale of 0 to 5, indicate your current situation 5
i We adjusted the number you entered based on the slider’s scale.

Question Title

* 10. On a scale of 0 to 5, please indicate your current situation:
0 = I have lots of energy
5 = I have no energy at all

0 On a scale of 0 to 5, indicate your current situation 5
i We adjusted the number you entered based on the slider’s scale.
Thank you for your ongoing participation. 

T