ATS Pulmonary Function Laboratory Manual

chapter  3

Appendix 3.3

[ ] Yes [ ] Yes

[ ] No [ ] No

9. Do you have, or have you ever had tuberculosis (TB)? If yes, is it active now?

[ ] Yes

[ ] No

10. Are you currently being treated for any infectious diseases?

If yes, what?

Do you cough? .11 If yes, do you bring up phlegm?

[ ] Yes [ ] Yes

[ ] No [ ] No

12. Have you had exposure to irritating gases, dusts, or fumes? If yes, what? _____________________________________________________ If yes, what and when? _____________________________________________ Do you require oxygen therapy? .41 15. What other medical problems do you currently have? _____________________ Have you done a breathing test in the past? .61 If yes, did you experience any problems (including, but not limited to 13. Have you ever had an injury or operation aŒecting your chest?

[ ] Yes

[ ] No

[ ] Yes

[ ] No

[ ] Yes

[ ] No

[ ] Yes

[ ] No

fainting, injury, or other adverse symptoms)?

[ ] Yes

[ ] No

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