Date of completion

1. In the last 2 weeks, have you had chest or stomach pain as a result of your cough?

2. In the last 2 weeks, have you been bothered by sputum (phlegm) production when you cough?

3. In the last 2 weeks, have you been tired because of your cough?

4. In the last 2 weeks, have you felt in control of your cough?

5. How often during the last 2 weeks have you felt embarrassed by your coughing?

6. In the last 2 weeks, my cough has made me feel anxious.

7. In the last 2 weeks, my cough has interfered with my job, or other daily tasks.

8. In the last 2 weeks, I felt that my cough interfered with the overall enjoyment of my life.

9. In the last 2 weeks, exposure to paint or fumes has made me cough.

10. In the last 2 weeks, has your cough disturbed your sleep?

11. In the last 2 weeks, how many times a day have you had coughing bouts?

12. In the last 2 weeks, my cough has made me feel frustrated.

13. In the last 2 weeks, my cough has made me feel fed up.

14. In the last 2 weeks, have you suffered from a hoarse voice as a result of your cough?

15. In the last 2 weeks, have you had a lot of energy?

16. In the last 2 weeks, have you worried that your cough may indicate serious illness?

17. In the last 2 weeks, have you been concerned that other people think something is wrong with you, because of your cough?

18. In the last 2 weeks, my cough has interrupted converstions or telephone calls.

19. In the last 2 weeks, I feel that my cough has annoyed my partner, family or friends.