The questionnaires of the vulnerability of patients with COPD.
How do you do? I am a staff of the study group of integrated intervening
COPD in community. According to the informed consent signed by you, now I
ask you something about your illness. After considering it, please answer me
seriously.
A. General characteristics
1. Address ：
Province
Municipality
County
Town
；
Village
2. Name：
3. Gender： (1) male (2) female
4. Nation：
5. blood type：
6.Date of birth：
7. Level of education: Illiteracy or semiliterate, elementary school, junior middle
school, senior high school and technical secondary school, above
junior college, unknown.
8. Marital status: Unmarried, Marriage, Divorce, Widowed, Separation, Unknown.
9.Occupation: Workers, Peasants, Herdsmen, Medical personnel, Clerks, Staff
members, Cadres, Teachers, Cook, Policemen, Drivers, Businessmen,
Retirees, Housework, Jobless, Students, Others
10.Average monthly household income ：
.
Yuan. Total members in
household
person(s)
B. Cognition for COPD
1. Have you heard of COPD?
(1) heard (2) Not heard(Go to 4) (3) Not remember
2. The level of your understanding of the knowledge of COPD.
(1) More systematic understanding
(2) known
(3) Understanding a little
(4) Not known
3. Do you know the meaning of acute exacerbation of COPD?
(1) More systematic understanding ( 2) Known
(3)Understanding a little
(4) Not known
4. You think you suffer from what disease?
1）COPD
2）Bronchitis ３）Asthma
4）Emphysema
5. The doctor had told you what disease you were suffering from?
１）COPD
２）Bronchitis３）Asthma 4）Emphysema
6. You think that your own health caused by which disease.
(1) COPD
(2)Bronchitis (3) Asthma (4) Emphysema
7.You think that the attack of
your disease was caused by which risk factors
（Maybe multi-select）.
(1) Got a cold
(2) Tired
smoking (6) Air pollution
(3) Cold weather
(7) Others
(4) Smoking
(5) Passive
.
8. Do you have a family history of chronic bronchitis (Do your parents, brothers
and sisters have chronic bronchitis).
(1) Yes
(2) No
(3) Not known
9. You think the impact degree of passive smoking on your disease.
(1) Very large (2) Larger (3) Common
(4) Smaller
10. Do you think the view that “The patient with chronic obstructive pulmonary
disease was frail? In order to reduce physical exertion, he should be resting.”
is right?
(1) Right
(2) Incorrect
(3) Not known
11. You think to participate in appropriate physical exercise for your disease.
(1) Very useful
(2) Useful (3) Little effect
(4) Not useful (5) Not known
12. You think the role of controlling chronic bronchitis for preventing
emphysema and Cor pulmonale.
(1) Very large
(2) Larger
(3) Common
(4) No role (5) Not known
13. Your attitude towards own disease.
(1) Very concerned about
concerned about
(2) More concerned about
(3) Ordinary
(4) Don’t matter
14. For the slow development of your disease, whether you took the relevant
measures ( Such as the prevention of cold, vaccination).
(1) Yes
( 2) No
15. For the slow development of your disease, whether you are willing to change
or control your behaviors (Such as quitting smoking, physical exercise).
（1）Very willing （2）Willing
（3）Not willing
（4）Don’t
matter
C. Behaviors
1. Do you have smoking?
(1) No (Go to 6)
(2) Current smoking
(3) Past smoking
2. How many years have you smoked
year(s)
3. The average number of your daily smoking
branch(es)
4. How long the time was from your last smoking to now
month(s).(Not
suit (2))
5. The mainly reason of your quitting smoking. (Not suit (2))
(1) Sick
limits
(2) Economic difficulties
(5) Public education
(3) Family against
(4) Environmental
(6) Others
6. Last year, did you often inhale the smoke exhaled by smokers (i.e. passive
smoking), and more than 15 minutes / day.
(1) Almost every day (2) More than three days per week
weekly (4) Less than one day per week
(5)
(3) Average of 1-3 days
No
7. How often did you cook?
(1) No（Go to 9）
(2) Less than one day per week
weekly (4) More than three days per week
8. How many years have you cooked
(3) Average of 1-3 days
(5) Almost every day
year(s)
9. Have you been in contact with dust or soot in the work in the past.
(1) Yes
(2) No
10. You think you lived in air pollution of your ambient.
(1) Very severe (2) More severe (3) Common severe
(4)
Less severe
11. Did you participate in physical exercise such as walking/ exercise/ dance/
play/ swimming/ running/ cycling/ Tai chi Etc.( Over 30 minutes /time/day)
(1) Every day(Once per day)
(2) Regular( More than three days per week) 3))
Irregular（Average of 1-3 days weekly） (4) Occasionally (Less than one day per
week
(5) No
12. Not to participate in physical exercise，what is the main reason.
(1) No time (2) Tired for work
conditions
(3) Do not like sports
(4) No place and
(5) Severe disease (6) Others
13. Did you participate in the rehabilitation exercises (such as breathing exercises,
hardy training, etc.).
(1) No (2) Less than 1 time per week
More than 3 times per week
(3) Average of 1-3 times weekly (4)
(5) Almost once a day
14. Why you did not participate in the rehabilitation exercises?
(1) No time (2) Tired for work (3) Not willing
(4) Not do
(5) Severe
disease (6) Others
15. Did you fear the onset of your disease, or because of your cough, sputum
symptoms that other people dislike, so you do not want to go to public
places(such as weddings, funerals , listening to the story, theatre).
(1) Yes
2）No
(3)
Don’t matter
D. Quality of life
Ⅰ.Self-assessed physical strength
(1) The same as common people.
(2) Shortness of breath with common work
(3) Shortness of breath with climbing stairs (40 Shortness of breath with light
activities.
(5) Shortness of breath when walking for one hundred steps.
Note: (1) ～(5) were 0 to 4 points.
Ⅱ.Activities of Daily Living (10 items)
1. Dressing, washing , brush teeth, combing, shaving ,haircut, etc.
（1）No shortness of breath, finishing by oneself（2）A little shortness of breath,
and can still finishing by oneself（3）More shortness of breath, need other people to
help complete（4）Obvious shortness of breath ,totally dependent on someone else
help complete
2. Bath
（1）Taking a bath
alone（2）Alone in bathing, felt shortness of breath（3）Because
of shortness of breath, need someone else to help with
bathing at home （4）
Because of shortness of breath, need someone else to help complete absolutely
3. Cook, housekeeping, laundry, sweeping, wiping tables, washing dishes and
other.
(1)No shortness of breath（2）A little shortness of breath（3）More shortness of
breath, and less to do. （4）Obviously gasp, and not to do.
4. Outdoor walking
(1) No shortness of breath，can walk more than 2000 meters away alone.（2）A little
shortness of breath, can walk 1 ～ 2 km away alone.（3）More shortness of breath,
can walk less than 1km away alone.（4）obviously gasp, can not walk over one
hundred steps.
5. Physical strength (Carry goods)
（1）No shortness of breath，can carry more than 10kg goods walking.（2）A little
shortness of breath, can carry 5 ～ 10kg goods walking.（3）More shortness of
breath, can carry 2 ～ 5kg goods walking.（4）Obviously gasp, can not nearly carry
goods to walk .
6. Upstairs
（1）Without a break, go upstairs 3rd floor or above.（2）Without a break, go upstairs
2 to 3 floor（3）Having a beak, go upstairs 2nd floor（4）Obviously gasp, can not
go upstairs alone.
7. Appetite
（1）Good appetite, have taste to eat（2）Common appetite（3）Bad appetite（4）
Do not want to diet.
8. Sleeping
（1）Sleep well（2）Because of shortness of breath and cough, poor sleep（3）Because
of shortness of breath and cough, wore sleep（4）Because of cough and dyspnea, can
not sleep all night or can not be supine.
9. Taking medicine
（1）Taking medicine consciously according to prescribed medication （2）
Occasionally need to be reminded taking drug （3）Often need to be reminded
taking drug（4）After reminding by someone else, often forgotten to take drug or
refused to take medicine.
10. Entertainment(reading newspaper, watching TV, listening to the radio,
playing chess, playing cards, etc.).
（1）Often(More than 1 h per day, over 4d per week)；
（2）Sometimes(0.5h per day,
over 3d per week)（3）Seldom(10 ～ 20 min per day,1～3d per week.)；（4）No.
Ⅲ.Social activities (4 items)
1. With neighbors , colleagues, relatives and friends and other.
（1）Often(Over 4 times monthly) （2）Many times(2 ～ 3 times monthly)（3）
Seldom (1 time monthly)（4）No.
2. Friends
（1）Liking to make friends and keep in close contact.（2）Having a friend, to maintain
general contact.（3）Little contact with friends.（4）No friends contact.
3. Social activities (neighborhood
activities , public activities, social part-time,
etc.).
（1）Participating all activities.（2）Regular participation (1 time or above per month)
（3）Sometimes participating(Less than 1 time per month)（4）No participating
4. Relationship with family
（1）Family members concern each other, mutual support, and often heart-to-heart
talk.（2）Can still communicate and support each other(1 time or above per week)
（3）Small of mutual supporting and exchange(Less than 1 time per week)（4）Not
mutually exchange.
Ⅳ. Psychological symptoms of depression(5 items)
1. Depressed for sick
（1）No.（2）Seldom(1 time per week) （3）More(2 ～ 3 times per week)；（4）
Often (4 times or above per week)
2. Feeling worthless
（1）No.（2）Seldom(1 time per week) （3）More(2 ～ 3 times per week)；（4）
Often (4 times or above per week)
3.Feeling happy and satisfaction to life
（1）Very satisfaction （2）Satisfaction（3）Fairly Satisfied（4）Dissatisfied
4. Worrying about COPD affecting self-health
（1）No.（2）Seldom worrying(1 time per week) （3）More worrying (2 ～ 3 times
per week)；（4）Often worrying (4 times or above per week)
5. Feel lonely
（1）No.（2）Seldom(1 time per week) （3）More(2 ～ 3 times per week)；（4）
Often (4 times or above per week)
Ⅴ. Psychological symptoms of anxiety (5 items)
1. Feeling easily fatigued
（1）No.（2）Seldom(1 time per week) （3）More(2 ～ 3 times per week) （4）
Often (4 times or above per week)
2. Feeling agitation
（1）No.（2）Seldom (1 time per week) （3）More(2 ～ 3 times per week)；（4）
Often (4 times or above per week)
3. Feeling impatient (Lost his temper for no reason)
（1）No.（2）Seldom (1 time per week) （3）More(2 ～ 3 times per week)；（4）
Often (4 times or above per week)
4. Feeling fear
（1）No.（2）Seldom(1 time per week) （3）More(2 ～ 3 times per week)；（4）
Often (4 times or above per week)
5. Having nightmares
（1）No.（2）Seldom(1 time per week) （3）More(2 ～ 3 times per week)；（4）
Often (4 times or above per week)
Note: ExceptⅠ, : (1) ～(4) of Ⅱ～Ⅴwere 1 to 4 points. The higher the score,
the worse the quality of life. “0”score mean that patients felt extremely well,
“1～20”scores mean very well, “21～40”scores mean 4 well, “41～60”scores
mean normal, “61～”scores mean bad.
E. Disease Management
1. Whether the local hold such as tobacco control, reasonable diet and other
health education and publicity.
(1) yes
(2) No
(3) Not remember
2. Whether you received, such as tobacco control, reasonable diet and other
health education and publicity.
(1) yes
(2) No
(3) Not remember
3. Are you willing to accept reasonable treatment?
(1) Willing
(2) Unwilling
（3）Don’t matter
4. The reason that you do not want to accept reasonable treatment.
（1）The disease was not severe
（2）Buy medicine by himself. （3）Financial
hardship （4）More distant road. （5）Not convenient for hospital services(such
as waiting too long.)
indicating
（6）No time （7）Not curable
（8) other(Please
)
5. Which of the following methods you had used for treatment of disease.
（1）Inhalation or aerosol agents. （2) Oxygen therapy （3）Pulmonary rehabilitation
（4） Surgery （5) No mentioned above.(Go to 7)
6. When you treated your COPD with using inhalation or aerosol agents, oxygen
therapy, pulmonary rehabilitation, do you use its according to the doctor
orders?
（1）yes
（2）no
7. The most drugs you used were at stable stage.
（1）Bronchodilators(such as aminophylline) 2）Antiinflammatory drugs(Such as
corticosteroids) 3）Antibiotics 4) Other (Please indicating
8. The most drugs you used were at acute exacerbation.
)
（1）Bronchodilators(such as aminophylline) （2）Antiinflammatory drugs(Such
as corticosteroids) （3）Antibiotics （4) Other (Please indicating:
)
9. In daily seeing doctors, which level medical institutions you often go to?
（1）County or above. （2）Health Centers （3）Village health clinic
（4）Private clinic.
10. When hospitalization, you often chose which level medical institutions
（1）Province （2）Municipal level （3）county （4）Health Centers.
F. Burden of disease
1. In last year, how many days you could not work due to COPD
Days
2. In last year, how many days your family members could not work for accompany
you because you got ill.
Days
3. In last year, how many traveling expenses you took for going to see doctors
Yuan.
4. In last year, how many traveling expenses your family members took for
accompanying you to see doctors
Yuan.
5. In last year, how many care expenses you took for nursing your disease
Yuan.
6. In last year, how many cash
you took for special purchase of nutritious food
Yuan.
7. In last year, the cost of hospitalization was
8. In last year, the cost of buying drugs was
Yuan.
Yuan in outpatient (Including
pharmacies, private clinics).
9. In last year, the cost of checkup was
Yuan for you got COPD.
10. In last year, your monthly net income
Yuan.
Above 10 items, the investigators should look patients’ records and invoices
related to medical treatment, while inquiring about patients.
The investigator Name:
Year
Patients coordinating (1) well
month
(2)common
day.
(3) bad