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Requested Illustration:

1. TYPE OF LUNG DISEASE:
CHRONIC BRONCHITIS
EMPHYSEMA
RESTRICTIVE LUNG DISEASE
ASTHMA

2. PLEASE LIST DATE WHEN FIRST DIAGNOSED

3. HAS THE CLIENT EVER BEEN HOSPITALIZED FOR THIS CONDITION? Yes No
IF YES, DETAIL DATE AND RESULTS:

4. HAS THE CLIENT EVER SMOKED?
YES, AND CURRENTLY SMOKES (AMOUNT/DAY)
YES, SMOKED IN THE PAST BUT QUIT
NO, NEVER SMOKED

5. IS YOUR CLIENT ON ANY MEDICATION OR AN INHALER FOR THE DISEASE: Yes No
IF YES, PLEASE GIVE DETAILS:

6. HAS THE CLIENT HAD A RECENT PULMONARY FUNCTION (BREATHING TEST)? Yes No
IF YES, PLEASE GIVE DETAILS:

7. DOES THE CLIENT HAVE ANY ABNORMALITIES ON AN ACG OR X-RAY? Yes No
IF YES, PLEASE GIVE DETAILS:

8. DOES THE CLIENT EXERCISE THREE OR MORE TIMES PER WEEK? Yes No
IF YES, PLEASE DETAIL

9. HAS A PARENT, BROTHER OR SISTER DIED PRIOR TO AGE 65, OTHER THAN BY ACCIDENT? Yes No
IF YES, PLEASE DETAIL

10. PLEASE LIST ANY OTHER ILLNESSES OR IMPAIRMENTS, ALONG WITH ANY AND ALL MEDICATIONS CURRENTLY BEING TAKEN, INCLUDE THE DOSAGE AND FREQUENCY OF EACH: