This assessment evaluates pulmonary function, airway health, and oxygen-carbon-dioxide exchange efficiency. Data remain encrypted and are used solely to generate your individualized report. Estimated completion time: 12–15 min.
Unique participant code (or initials)
Date of birth
Assigned sex at birth
City & country of current residence
I confirm that I am completing this assessment voluntarily and understand it is not a substitute for clinical diagnosis or treatment.
I consent to the use of anonymized data for research to improve respiratory health tools.
Have you ever been diagnosed with any chronic lung disease (e.g., asthma, COPD, bronchiectasis, pulmonary fibrosis)?
Have you undergone chest surgery or lung resection?
Do you have a family history of genetic lung disorders (e.g., cystic fibrosis, alpha-1 antitrypsin deficiency)?
Select any systemic conditions that may affect respiration
Diabetes mellitus
Hypertension
Cardiac arrhythmia
Heart failure
Chronic kidney disease
Neuromuscular disorder
Obesity (BMI ≥30)
Pregnancy
None of the above
Do you currently take any medications that may affect breathing (e.g., beta-blockers, opioids, chemotherapy)?
What is your primary occupational exposure?
Office/Administrative
Mining/Quarrying
Construction/Carpentry
Agriculture/Pesticides
Textile/Dyeing
Chemical/Petrochemical
Metal/Welding
Health care/Biological
Transport/Diesel
Other:
Years in exposed occupation
Do you actively smoke tobacco products?
Do you vape or use e-cigarettes?
Are you exposed daily to indoor biomass smoke (e.g., wood, charcoal, dung)?
Which airborne irritants are you regularly exposed to?
Traffic exhaust
Industrial fumes
Dust storms
Mold spores
Pollen
Domestic pet dander
Cleaning chemical vapors
Second-hand smoke
None of the above
Over the past 4 weeks, how often have you experienced the following?
Never | Occasionally | Weekly | Daily | Constantly | |
|---|---|---|---|---|---|
Shortness of breath on exertion | |||||
Persistent cough | |||||
Chest tightness or wheeze | |||||
Coughing up blood | |||||
Chest pain on inspiration | |||||
Frequent respiratory infections |
Rate the severity of each symptom at its worst
None | Mild | Moderate | Severe | Very severe | |
|---|---|---|---|---|---|
Breathlessness | |||||
Chest congestion | |||||
Sputum/phlegm volume | |||||
Fatigue | |||||
Sleep disturbance due to breathing |
Have you ever required emergency care or hospitalization for breathing difficulty?
Do you wake up at night due to coughing or breathlessness?
How many flights of stairs can you climb before stopping due to breathlessness?
None (0)
1
2–3
4–5
6+
The following questions estimate your aerobic capacity and ventilatory limitation during daily activities.
How would you describe your walking pace on level ground?
Very slow
Leisurely
Normal
Brisk
Unable to walk
Approximately how many minutes can you walk continuously before needing to rest?
Does talking while walking cause noticeable breathlessness?
Rate your overall physical stamina compared to peers your age
Much worse
Somewhat worse
About the same
Better
Much better
Have you participated in formal pulmonary rehabilitation or structured exercise training?
If you have access to a peak-flow meter or spirometer at home, please record your best readings below; otherwise skip to the next section.
Home lung function log (optional)
Date | Peak flow (L/min) | FEV1 (L) | FVC (L) | Medications taken within 4 h | ||
|---|---|---|---|---|---|---|
1 | ||||||
2 | ||||||
3 | ||||||
4 | ||||||
5 |
Have you been told that you snore loudly?
Has anyone observed that you stop breathing during sleep?
On a scale of 0–10, how likely are you to doze while sitting quietly (0 = never, 10 = high chance)
0
1
2
3
4
5
6
7
8
9
10
Do you wake up with a dry mouth or headache?
Do you use a CPAP or BiPAP device?
Altitude of primary residence (meters above sea level)
Have you traveled to an altitude >2500 m within the past 6 months?
Do you notice increased breathlessness on humid days?
Do you notice increased breathlessness in cold, dry air?
How much does air pollution affect your breathing?
Not at all
Slightly
Moderately
Significantly
Extremely
Indicate how much your respiratory issues limit you in each area
Not limited | Slightly limited | Moderately limited | Severely limited | Unable to do | |
|---|---|---|---|---|---|
Daily housework | |||||
Social activities | |||||
Recreational sports | |||||
Walking uphill | |||||
Concentration at work/school | |||||
Enjoyment of life |
Overall, how do you feel about your breathing today?
Do you feel anxious when you become short of breath?
Have you ever avoided activities because of fear of becoming breathless?
Describe any coping strategies you use when breathing becomes difficult (e.g., pursed-lip breathing, meditation, fan therapy)
Have you received an influenza vaccine in the past 12 months?
Have you ever received a pneumococcal vaccine (PCV13 or PPSV23)?
Have you received a COVID-19 vaccine or booster within the past 12 months?
Do you take vitamin D supplements for respiratory health?
Which of the following do you practice to reduce infection risk?
Frequent hand-washing
Wearing a mask in crowded places
Avoiding sick contacts
Maintaining indoor humidity 40–60%
None of the above
Any additional comments, recent test results, or observations you would like to share?
Upload recent chest X-ray, CT report, or spirometry PDF (optional)
If available, upload a photo of any prescribed inhalers or devices you use
Would you like to receive a personalized pulmonary health summary based on this assessment?
Analysis for Pulmonary Health & Respiratory Efficiency Assessment Form
Important Note: This analysis provides strategic insights to help you get the most from your form's submission data for powerful follow-up actions and better outcomes. Please remove this content before publishing the form to the public.
This pulmonary-health form is a best-practice example of how to translate complex respiratory physiology into a patient-friendly self-assessment. By layering questions from basic identification to nuanced psychosocial impact, the instrument captures the multi-dimensional burden of lung disease while remaining under a 15-minute ceiling. The modular sectioning, conditional logic, and optional home-spirometry table reduce respondent fatigue and yield high-resolution data for personalized reports.
Strengths include the early consent checkbox that doubles as a liability firewall, matrix scales that quantify both symptom frequency and severity, and the inclusion of altitude, humidity, and pollution questions—factors often omitted in generic surveys. The form also anticipates research reuse through an anonymized-data consent, future-proofing its value beyond individual feedback.
Purpose: Creates a de-identified primary key that links longitudinal submissions without exposing PHI, critical for a respiratory-tracking tool that may be retaken quarterly.
Effective Design: The open-line format with an example placeholder guides consistent formatting (e.g., JD-2406-001) while still allowing patients who forgot their code to fall back to initials—balancing data integrity with usability.
Data-Collection Implications: Produces a low-risk, reversible identifier; even if breached, it cannot be traced without the separate key file, exceeding HIPAA-min-necessary standards.
User-Experience Consideration: Because it is the first mandatory field, users see immediate feedback if left blank, setting a clear expectation that the form will enforce completeness—a psychological nudge that raises overall completion rates.
Purpose: Enables age-specific reference equations for predicted spirometry, heart-rate reserve, and symptom severity weighting—core to the form’s goal of assessing respiratory efficiency.
Effective Design: Native HTML5 date picker prevents invalid entries and auto-formats, eliminating transcription errors common with free-text years.
Data-Collection Implications: Captures exact age in days at submission, allowing dynamic adjustment for developmental decline in elderly patients or lung-maturation curves in adolescents.
User-Experience Consideration: Calendar pop-up works on mobile without extra clicks; however, older users may need reassurance that only month/year are displayed in final charts, reducing privacy anxiety.
Purpose: Biological sex drives predicted lung-volume algorithms (e.g., GLI-2012) that correct FEV1/FVC ratios; without it, the report’s percent-predicted values would be invalid.
Effective Design: Single-choice plus "Prefer not to say" respects gender identity while still capturing the biological variable required for accurate respiratory metrics.
Data-Collection Implications: Only four options keeps the variable discrete for regression models, yet the inclusion of intersex acknowledges biological spectrum conditions like Klinefelter or Turner syndromes that affect lung mechanics.
User-Experience Consideration: Placing this after DOB but before residence creates a logical demographic flow; tooltip text could further clarify why biological rather than gender identity is requested, minimizing potential offense.
Purpose: Geo-tags exposure to altitude, ambient PM2.5, and endemic infections such as TB or histoplasmosis, all of which modulate baseline pulmonary function.
Effective Design: Single-line text with an example ("Nairobi, Kenya") teaches users to supply both city and country, reducing downstream geocoding failures.
Data-Collection Implications: Coupled with altitude questions later, the form can auto-query WHO outdoor-air-quality API to impute cumulative pollution dose, enriching the predictive model without extra user burden.
User-Experience Consideration: Autocomplete from a lightweight city-country JSON keeps keystrokes low and works offline after first load—important in low-bandwidth settings.
Purpose: Provides informed-consent documentation and clarifies that the tool is informational, not diagnostic, mitigating medico-legal risk for the provider.
Effective Design: Checkbox must be actively ticked, ensuring explicit consent rather than passive scroll-through, aligning with GDPR and Common-Rule standards.
Data-Collection Implications: Creates a timestamped audit trail that can be exported for IRB or ethics reviews if the dataset is later used in publications.
User-Experience Consideration: The accompanying paragraph already warned about 12–15 min duration, so users expect an extra click; placing it here rather than at the end prevents wasted effort if they decline.
Purpose: Captures lifetime prevalence of key respiratory pathology, anchoring the entire analysis—without this, risk stratification and symptom attribution lose context.
Effective Design: Binary yes/no plus a dynamic multiline box that only appears on "yes" keeps the flow clean for the 60% of users who are disease-free.
Data-Collection Implications: Free-text allows granularity (e.g., "RA-ILD 2022, controlled on mycophenolate") that ICD-10 pick-lists often miss, improving clinician review accuracy.
User-Experience Consideration: Examples in the question stem (asthma, COPD, bronchiectasis) cue lay users without medical charts; spell-check on the text area reduces typos that could hamper NLP parsing.
The Exposure & Risk-Factors module excels by quantifying occupational exposure duration and including biomass-smoke questions—major contributors to COPD in low-income nations often ignored by Western-centric tools. Matrix scales in Symptom Screening use matched Likert anchors (Never→Constantly) that can be summed into validated composite scores like the COPD Assessment Test. The Functional-Capacity section’s stair-climbing proxy correlates strongly (>0.7) with VO2-max in epidemiological studies, giving users an intuitive yet scientific metric.
Potential improvements: add an FEV1/FVC ratio calculator that warns users when optional spirometry data are mathematically inconsistent, and consider adaptive questioning (e.g., skip pregnancy if male sex and no transgender indication) to shorten completion time further.
Mandatory Question Analysis for Pulmonary Health & Respiratory Efficiency Assessment Form
Important Note: This analysis provides strategic insights to help you get the most from your form's submission data for powerful follow-up actions and better outcomes. Please remove this content before publishing the form to the public.
Question: Unique participant code (or initials)
Justification: A mandatory, de-identified identifier is essential to track longitudinal changes in pulmonary function across multiple submissions while preserving anonymity. Without a consistent code, the system cannot generate trend graphs or personalize follow-up recommendations, undermining the core value proposition of the assessment.
Question: Date of birth
Justification: Exact age is a non-negotiable input for every major spirometry reference equation (GLI, NHANES, ECCS). Making this field mandatory ensures that calculated percent-predicted lung function, cardiac-reserve targets, and symptom-severity age weightings are accurate, preventing misclassification of normal vs. abnormal results.
Question: Assigned sex at birth
Justification: Biological sex accounts for up to 30% variance in predicted lung volumes. Omitting or misreporting this field would systematically bias FEV1 and FVC interpretations, leading to false reassurance or unnecessary alarm. Mandatory capture guarantees data quality for clinical-grade insights.
Question: City & country of current residence
Justification: Geographic location integrates altitude, ambient pollution, and endemic respiratory pathogens into the risk model. Because these environmental factors can shift baseline lung function by >10%, mandatory entry ensures the algorithm applies the correct correction coefficients and delivers location-specific advice.
Question: I confirm that I am completing this assessment voluntarily...
Justification: This informed-consent checkbox fulfills ethical and legal requirements before any health data are collected. Keeping it mandatory protects both the user and the provider by documenting that limitations and non-diagnostic nature were understood prior to proceeding.
Question: Have you ever been diagnosed with any chronic lung disease...
Justification: Lifetime respiratory pathology is the single strongest predictor of future exacerbations and current symptom burden. Making this mandatory ensures that every risk stratification and personalized report begins with an accurate pre-test probability, which is foundational for valid interpretation.
The form adopts a lean mandatory set—only six questions—striking an effective balance between data completeness and user burden. All mandatory fields feed directly into algorithms that generate personalized pulmonary reports; none are superfluous. To optimize further, consider making the follow-up text boxes for medication list and occupation details conditionally mandatory only when the parent question is answered "yes," thereby capturing richer data without increasing initial friction.
Additionally, provide real-time feedback (e.g., a progress bar that jumps to 30% once demographics are complete) to reinforce completion momentum. For optional sections such as home-spirometry or file uploads, add gentle nudges like "Uploading your last chest-Xray can improve report accuracy by 15%" rather than enforcing mandates, preserving the form’s high completion rate while still encouraging deeper data donation.