CDC ACE study – health questions women

Health Appraisal Questionnaire
Female Version
Do you have:
Frequent stuffy or watery nose, sneezing
1=yes
2=no
An allergy to any medications
1=yes
2=no
Asthma or notice yourself wheezing
1=yes
2=no
Chronic bronchitis or emphysema
1=yes
2=no
A frequent cough for any reason
1=yes
2=no
Shortness of breath
1=yes
2=no
Have you ever:
Coughed up blood (coughed not vomited)
1=yes
2=no
Been treated for TB or Coccidomycosis (Valley Fever)
1=yes
2=no
Had a positive TB test
1=yes
2=no
Been a smoker
1=yes
2=no
If now a smoker how many cigarettes a
day _________
1

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