Appendix 2: Postal questionnaire

Code: ______

Newcastle and North Tyneside Respiratory Questionnaire

PRIVATE AND CONFIDENTIAL

Thank you for filling in this questionnaire. We hope you will find it interesting and easy to complete.

Your reply will be kept in strict confidence. There is no need to write your name anywhere on this booklet.

When you have answered the questions, please put the booklet in the envelope provided.

No stamp is needed.

NOW PLEASE TURN THIS PAGE, AND READ THE INSTRUCTIONS INSIDE THE FRONT COVER BEFORE STARTING AT QUESTION 1.

INSTRUCTIONS FOR ANSWERING QUESTIONS

THESE ARE SAMPLE QUESTIONS.

DO NOT ANSWER THEM.

There are several types of question in this booklet. Most of them can be answered easily by ticking a box.

For example:

Q. Do you wear glasses? □ □

YES NO

A few questions ask you to write in your answer on a dotted line.

For example:

Q.  State briefly for how long have you worn glasses? (please specify)

……3…. years

Some questions ask you to tick more than one box.

For example:

Q.  Which people in your household wear glasses?

Please tick any that apply

Spouse or partner □

Children □

Parents □

Please remember it is YOUR PERSONAL VIEWS we are interested in, there are no right or wrong answers for these questions. You may ask someone, for example a member of your family or a friend, to help you fill in the questionnaire, but the answers should still be your views.

THANK YOU – PLEASE START NOW AT QUESTION ONE

ON THE NEXT PAGE.

FIRSTLY, SOME GENERAL QUESTIONS

1. What is today`s date? □□ □□ □□□□

DAY MONTH YEAR

2. What is your date of birth? □□ □□ □□□□ DAY MONTH YEAR

3. Are you male or female? □ □

MALE FEMALE

4. How long have you been at your present address? ……… years

5.  Where have you lived for most of your life? (tick one)

Present address or within about half a mile □

Elsewhere in the North East □

Other parts of the country or abroad □

6.  What is your current employment status? (tick one)

Employed full-time □

Employed part-time □

Looking for work □

Retired □

Other (housewife, student) □

please specify:…………………………

7.  Have you ever worked in any of the following and if so for how long?: (tick

any that apply)

Ever worked in For how long For how many

days a week?

Coal mining □ …... years …… days a week Shipyard work □ …… years …… days a week

Factory work □ …… years …… days a week

Paint spraying □ …… years …… days a week

Dusty/fume filled □ …… years …… days a week

environments

Welding □ …… years …… days a week

Asbestos □ …… years …… days a week Farming □ …... years …… days a week

Solvents □ …… years …… days a week

Foundry □ …… years …… days a week

Cleaning □ …… years …… days a week

8.  Is the house you live in:

Owned □

Rented □

Other – please specify □

…………………………………………………………..

NOW SOME QUESTIONS ABOUT YOUR HEALTH AND BREATHING

9.  Do you have any long-term illness, health problem or disability which

limits what you can do? □ □

YES NO

IF “NO” GO TO QUESTION 10

IF “YES” please tell us what this problem is: ………………………….

10.  Do you have any of the following (tick all that apply)

a) Heart problems □ □

YES NO

b) Stroke □ □

YES NO

c) Arthritis or other joint problems □ □

YES NO

d) Osteoporosis □ □

YES NO

e)  Other - please specify: ………………………………………………

11. Do you have a cough on most days? □ □

YES NO

12. Do you bring up phlegm / sputum □ □

YES NO

13. Are you troubled by breathlessness? □ □

YES NO

IF “NO” GO TO QUESTION 14

IF “YES”:

13.1 Are you short of breath hurrying on the level □ □

or walking up a slight hill? YES NO

13.2 Do you walk slower than most people on □ □

the level? YES NO

13.3 Do you have to stop for breath after walking □ □

about 100 yards on the level? YES NO

13.4 Are you too breathless to leave home but □ □

can undress without help? YES NO

13.5 Are you too breathless to leave home and too □ □

breathless to undress without help? YES NO

14. Have you at any time been wheezy? (This means □ □

you have heard a whistling sound, however high YES NO

or low pitched and faint coming from your chest)

IF “NO” GO TO QUESTION 16

IF “YES”:

15. Were you wheezy or breathless as a child? □ □ YES NO

16. Do you suffer with hay fever or any other allergies that □ □

make your nose runny or stuffy, apart from colds? YES NO

17.  Has a doctor ever diagnosed you with any of the following?:

Asthma □ □

YES NO

Emphysema □ □

YES NO

Chronic Bronchitis □ □

YES NO

Chronic Obstructive Airways Disease (COPD) □ □

YES NO

18. Have you used any medicines (inhalers, tablets) □ □

to help your chest in the last 12 months? YES NO

If “NO” please go to question 19

If “YES”:

18.1 Which of the following have you used? (tick all that apply)

a) Inhalers □ □

YES NO

b) Antibiotics □ □

YES NO

c) Steroid (Prednisolone) tablets □ □ YES NO

d) Oxygen □ □ YES NO

e) Nebulisers □ □

YES NO

f) Other (please specify) ……………………..….

NOW SOME QUESTIONS ABOUT SMOKING

19. Have you ever smoked? □ □

YES NO

If “NO” go to question 20

If “YES”:

19.1 How old were you when you started? ………….. years old

19.2 If you stopped, how old were you then? ………….. years old

19.3 Were you a regular pipe or cigar smoker? □ □

YES NO

19.4  If not, how many cigarettes did you

usually smoke? …….. cigarettes a day

20. Would you be willing to attend for some breathing □ □

tests as part of this study? YES NO

21. Are you currently taking part in any other medical □ □

research project? YES NO

IF “YES” what is it? ……………………………………………………………

If you have anything else to say about your breathing please

add your comments below.

PLEASE CHECK THAT YOU HAVE ANSWERED ALL OF THE QUESTIONS, EVEN THE NO ANSWERS. PLEASE USE THE ENCLOSED FREEPOST ENVELOPE TO RETURN THE QUESTIONNAIRE, NO STAMP IS REQUIRED.

THANK YOU FOR YOUR HELP AND TIME.

If you have any problems completing this questionnaire or have any queries, please do not hesitate to contact Michael Mason at the address or telephone number given below.

Department of Respiratory Medicine

Royal Victoria Infirmary

Queen Victoria Road

Newcastle upon Tyne

NE1 4LP

Tel: 07956 396371

e-mail:

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