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Respiratory Health Survey-P3-PostTraining-HE
As part of our research, we would like to know more about your respiratory health and to learn how recently you have experienced symptoms.
Thank you for your involvement, time and efforts!
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1.
ID and Zip/Postal Codes
(Required.)
Your ID Code
ZIP/Postal Code
*
2.
Please enter today's date:
(Required.)
*
3.
Please indicate the last time you recall having symptoms of each of these conditions.
(Required.)
Within the last 30 days.
Three to twelve months ago.
One to five years ago.
More than 5 years ago.
I do not recall/ Not applicable
I prefer not to respond to this question.
Sinusitis or Rhino-sinusitis
Within the last 30 days.
Three to twelve months ago.
One to five years ago.
More than 5 years ago.
I do not recall/ Not applicable
I prefer not to respond to this question.
Chronic Obstructive Pulmonary Disease or other lung dysfunction (other than asthma)
Within the last 30 days.
Three to twelve months ago.
One to five years ago.
More than 5 years ago.
I do not recall/ Not applicable
I prefer not to respond to this question.
Tonsillitis or other throat infections
Within the last 30 days.
Three to twelve months ago.
One to five years ago.
More than 5 years ago.
I do not recall/ Not applicable
I prefer not to respond to this question.
Pneumonia or influenza
Within the last 30 days.
Three to twelve months ago.
One to five years ago.
More than 5 years ago.
I do not recall/ Not applicable
I prefer not to respond to this question.
Bronchitis
Within the last 30 days.
Three to twelve months ago.
One to five years ago.
More than 5 years ago.
I do not recall/ Not applicable
I prefer not to respond to this question.
Asthma
Within the last 30 days.
Three to twelve months ago.
One to five years ago.
More than 5 years ago.
I do not recall/ Not applicable
I prefer not to respond to this question.
Allergies or reactivity to airborne irritants
Within the last 30 days.
Three to twelve months ago.
One to five years ago.
More than 5 years ago.
I do not recall/ Not applicable
I prefer not to respond to this question.
Cough
Within the last 30 days.
Three to twelve months ago.
One to five years ago.
More than 5 years ago.
I do not recall/ Not applicable
I prefer not to respond to this question.
Laryngitis or hoarseness
Within the last 30 days.
Three to twelve months ago.
One to five years ago.
More than 5 years ago.
I do not recall/ Not applicable
I prefer not to respond to this question.
Mouth or gum infections
Within the last 30 days.
Three to twelve months ago.
One to five years ago.
More than 5 years ago.
I do not recall/ Not applicable
I prefer not to respond to this question.
Ear infections
Within the last 30 days.
Three to twelve months ago.
One to five years ago.
More than 5 years ago.
I do not recall/ Not applicable
I prefer not to respond to this question.
4.
In your own experience, please tell us about any triggers that are associated with nasal or sinus congestion or infection. Please include both environmental triggers and other health associated factors that may be related to onset or duration of these problems.
5.
Regarding the wellness activities that are part of your life, please indicate any category in which you have participated over the last year. Select as many as apply. Select the frequency category that best applies to your activities.
None
Less than 10 minutes a week
Less than an hour a week
2 to 6 hours per week
7 to 15 hours per week
16 or more hours per week
Meditative movement (Tai Chi, Qigong, Yoga, or similar)
None
Less than 10 minutes a week
Less than an hour a week
2 to 6 hours per week
7 to 15 hours per week
16 or more hours per week
Seated meditation
None
Less than 10 minutes a week
Less than an hour a week
2 to 6 hours per week
7 to 15 hours per week
16 or more hours per week
Strength training (Weight training, resistance machines, or similar)
None
Less than 10 minutes a week
Less than an hour a week
2 to 6 hours per week
7 to 15 hours per week
16 or more hours per week
Endurance (Aerobic ) training (Walking, running, jogging, cycling, etc)
None
Less than 10 minutes a week
Less than an hour a week
2 to 6 hours per week
7 to 15 hours per week
16 or more hours per week
Sports
None
Less than 10 minutes a week
Less than an hour a week
2 to 6 hours per week
7 to 15 hours per week
16 or more hours per week
Occupational activity that you feel supports your wellness.
None
Less than 10 minutes a week
Less than an hour a week
2 to 6 hours per week
7 to 15 hours per week
16 or more hours per week
Calisthenic type activities (Zumba, Pilates, etc)
None
Less than 10 minutes a week
Less than an hour a week
2 to 6 hours per week
7 to 15 hours per week
16 or more hours per week
Other
None
Less than 10 minutes a week
Less than an hour a week
2 to 6 hours per week
7 to 15 hours per week
16 or more hours per week
Other (please specify)
Thank you for your time and commitment to this project!