Pulmonary Rehabilitation Program
Responses to the questions below will help us understand the impact of the symptoms of your lung condition on the your quality of life.
Patient ID
*
Date of Ax
*
-
Month
-
Day
Year
Therapist's initial
*
ZA
SS
PS
SA
PT student
A. Modified-MRC Scale
(mMRC)
Please CHOOSE ONE OPTION that best describes your breathing:
*
0- I am not troubled by breathlessness except on strenuous exercise
1- I get short of breath when hurrying on the level or walking up a slight hill
2- I walk slower than most people on the level, or have to stop for breath when walking at my own pace on the level
3- I stop for breath after walking about 100 yards or after a few minutes on level ground
4- I am too breathless to leave the house, or am breathless when undressing
B) The Kings Brief Interstitial Lung Disease Questionnaire (K-BLID)
Please choose the most appropriate response to the statements 1-15 below.
1. In the last 2 weeks I have been breathless climbing stairs or walking up an incline or hill
*
1. Every time
2. Most times
3. Several times
4. Some times
5. Occasionally
6. Rarely
7. Never
2. In the last 2 weeks, because of my lung condition, my chest has felt tight
*
1. ALL OF THE TIME
2. MOST OF THE TIME
3. A GOOD BIT OF THE TIME
4. SOME OF THE TIME
5. A LITTLE OF THE TIME
6. HARDLY ANY OF THE TIME
7. NONE OF THE TIME
3. In the last 2 weeks have you been worried about the seriousness of your lung complaint?
*
1. ALL OF THE TIME
2. MOST OF THE TIME
3. A GOOD BIT OF THE TIME
4. SOME OF THE TIME
5. A LITTLE OF THE TIME
6. HARDLY ANY OF THE TIME
7. NONE OF THE TIME
4. In the last 2 weeks have you avoided doing things that make you breathless?
*
1. ALL OF THE TIME
2. MOST OF THE TIME
3. A GOOD BIT OF THE TIME
4. SOME OF THE TIME
5. A LITTLE OF THE TIME
6. HARDLY ANY OF THE TIME
7. NONE OF THE TIME
5. In the last 2 weeks have you felt in control of your lung condition?
*
1. NONE OF THE TIME
2. A LITTLE OF THE TIME
3. SOME OF THE TIME
4. A GOOD BIT OF THE TIME
5. MOST OF THE TIME
6. ALMOST ALL OF THE TIME
7. ALL OF THE TIME
6. In the last 2 weeks, has your lung complaint made you feel fed up or down in the dumps?
*
1. ALL OF THE TIME
2. MOST OF THE TIME
3. A GOOD BIT OF THE TIME
4. SOME OF THE TIME
5. A LITTLE OF THE TIME
6. HARDLY ANY OF THE TIME
7. NONE OF THE TIME
7. In the last 2 weeks, I have felt the urge to breathe, also known as 'air hunger'
*
1. ALL OF THE TIME
2. MOST OF THE TIME
3. A GOOD BIT OF THE TIME
4. SOME OF THE TIME
5. A LITTLE OF THE TIME
6. HARDLY ANY OF THE TIME
7. NONE OF THE TIME
8. In the last 2 weeks, my lung condition has made me feel anxious
*
1. ALL OF THE TIME
2. MOST OF THE TIME
3. A GOOD BIT OF THE TIME
4. SOME OF THE TIME
5. A LITTLE OF THE TIME
6. HARDLY ANY OF THE TIME
7. NONE OF THE TIME
9. In the last 2 weeks, how often have you experienced 'wheeze' or whistling sounds from you chest?
*
1. ALL OF THE TIME
2. MOST OF THE TIME
3. A GOOD BIT OF THE TIME
4. SOME OF THE TIME
5. A LITTLE OF THE TIME
6. HARDLY ANY OF THE TIME
7. NONE OF THE TIME
10. In the last 2 weeks, how much of the time have your felt your lung disease is getting worse?
*
1. ALL OF THE TIME
2. MOST OF THE TIME
3. A GOOD BIT OF THE TIME
4. SOME OF THE TIME
5. A LITTLE OF THE TIME
6. HARDLY ANY OF THE TIME
7. NONE OF THE TIME
11. In the last 2 weeks, has your lung condition intefered with your job or other daily tasks?
*
1. ALL OF THE TIME
2. MOST OF THE TIME
3. A GOOD BIT OF THE TIME
4. SOME OF THE TIME
5. A LITTLE OF THE TIME
6. HARDLY ANY OF THE TIME
7. NONE OF THE TIME
12. in the last 2 weeks have you expected your lung complaint to get worse?
*
1. ALL OF THE TIME
2. MOST OF THE TIME
3. A GOOD BIT OF THE TIME
4. SOME OF THE TIME
5. A LITTLE OF THE TIME
6. HARDLY ANY OF THE TIME
7. NONE OF THE TIME
13. In the last 2 weeks, how much has your lung condition limited your carrying things, for eg. groceries?
*
1. ALL OF THE TIME
2. MOST OF THE TIME
3. A GOOD BIT OF THE TIME
4. SOME OF THE TIME
5. A LITTLE OF THE TIME
6. HARDLY ANY OF THE TIME
7. NONE OF THE TIME
14. In the last 2 weeks, has your lung condition made you think about the end of your life?
*
1. ALL OF THE TIME
2. MOST OF THE TIME
3. A GOOD BIT OF THE TIME
4. SOME OF THE TIME
5. A LITTLE OF THE TIME
6. HARDLY ANY OF THE TIME
7. NONE OF THE TIME
15. Are you financially worse off because of your lung condition?
*
1. A significant amount
2. A large amount
3. A considerable amount
4. A reasonable amount
5. A small amount
6. Hardly at all
7. Not at all
Thank you for completing this form.
Date of completion
*
-
Month
-
Day
Year
Date
Breathlessness and Activities
Total
Psychological
Chest symptoms
Submit
Should be Empty: