17 | Discomfort in your chest Yes = 1, No = 2, Don’t Know = 3, 8 = Not applicable, 9 = No Response If yes, state where it occurs: Upper sternum Yes = 1, No = 2, Don’t Know = 3, 8 = Not applicable, 9 = No Response Lower sternum Yes = 1, No = 2, Don’t Know = 3, 8 = Not applicable, 9 = No Response Left anterior chest Yes = 1, No = 2, Don’t Know = 3, 8 = Not applicable, 9 = No Response Other Yes = 1, No = 2, Don’t Know = 3, 8 = Not applicable, 9 = No Response If other (specify) Do you get it: When walk at ordinary pace Yes = 1, No = 2, Don’t Know = 3, 8 = Not applicable, 9 = No Response What do you do when you get it while you are walking? Stop or slow down = 1, Carry on = 2, Don’t Know = 3, 8 = Not applicable, 9 = No Response Is it relieved if you stand still? Yes = 1, No = 2, Don’t Know = 3, 8 = Not applicable, 9 = No Response If yes 1 = After less than 10 Min, 2 = More or equal 10 Min Precipitating factors: Exertion Yes = 1, No = 2, Don’t Know = 3, 8 = Not applicable, 9 = No Response Emotion Yes = 1, No = 2, Don’t Know = 3, 8 = Not applicable, 9 = No Response Cold weather Yes = 1, No = 2, Don’t Know = 3, 8 = Not applicable, 9 = No Response If other yes, specify |
18 | Do you get pain in your leg Yes = 1, No = 2, Don’t Know = 3, 8 = Not applicable, 9 = No Response If yes, specify where Calf pain Yes = 1, No = 2, Don’t Know = 3, 8 = Not applicable, 9 = No Response If calf pain, does this pain occur when: Either standing or sitting? Yes = 1, No = 2, Don’t Know = 3, 8 = Not applicable, 9 = No Response Hurrying or walking uphill? Yes = 1, No = 2, Don’t Know = 3, 8 = Not applicable, 9 = No Response Walking at ordinary pace Yes = 1, No = 2, Don’t Know = 3, 8 = Not applicable, 9 = No Response Does the pain ever disappear while you are walking? Yes = 1, No = 2, Don’t Know = 3, 8 = Not applicable, 9 = No Response What do you do if you get it while you are walking? Stop or slow down = 1, Carry on = 2, Don’t Know = 3, 8 = Not applicable, 9 = No Response Is it relieved when you stand still? Yes = 1, No = 2, Don’t Know = 3, 8 = Not applicable, 9 = No Response If yes, After less than 10 Min = 1, More than or equal 10 Min = 2, Don’t Know = 3, 8 = Not applicable, 9 = No Response |
19 | When hurrying on level ground or walking up a slight hill? Yes = 1, No = 2, Don’t Know = 3, 8 = Not applicable, 9 = No Response When walking with other people of your own age on level ground Yes = 1, No = 2, Don’t Know = 3, 8 = Not applicable, 9 = No Response Do you have to stop for breath when walking at your pace on level ground? Yes = 1, No = 2, Don’t Know = 3, 8 = Not applicable, 9 = No Response Are you short of breath on washing or dressing? Yes = 1, No = 2, Don’t Know = 3, 8 = Not applicable, 9 = No Response |