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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

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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

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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