Specify if the patient has ever had any of the following conditions:
Asthma or chronic lung disease (e.g. emphysema, COPD, chronic bronchitis)? – Select Yes or No.
With Yes selected, a set of responses (Date and Description) is available.
For each additional set of responses you want to add, click Add More. You can add up to four additional sets of responses.
Note: To delete an additional set of responses, click the corresponding Delete button 
.
Optionally, select a year and/or description for each set of responses:
Date - Select a year or Unknown. If a year is selected, to specify that the year is approximate, select the Approximate Date checkbox.
Description - Select one of the following descriptions:
Asthma.
Exercise Induced Asthma.
Allergy Induced Asthma.
Status Asthmaticus (History of).
Emphysema.
COPD.
Chronic Bronchitis.
Lung Cancer.
Pulmonary Embolism.
Pulmonary Fibrosis.
Uses Supplemental Oxygen.
Other – With this option selected, an Add description box is available. Optionally, enter up to 60 characters.
Tuberculosis, histoplasmosis, cystic fibrosis, blastomycosis? – Select Yes or No.
With Yes selected, a set of responses (Date and Description) is available.
For each additional set of responses you want to add, click Add More. You can add up to four additional sets of responses.
Note: To delete an additional set of responses, click the corresponding Delete button .
Optionally, select a year and/or description for each set of responses:
Date - Select a year or Unknown. If a year is selected, to specify that the year is approximate, select the Approximate Date checkbox.
Description - Select one of the following descriptions:
Tuberculosis.
Histoplasmosis.
Cystic Fibrosis.
Blastomycosis.
Coccidioidomycosis (Valley Fever).
Other – With this option selected, an Add description box is available. Optionally, enter up to 60 characters.