Welcome to your Lung Function Assessment At Siesta Sleep & Respiratory your privacy is important to us! We would like to reassure you that your lung function assessment responses will be kept confidential and will not be misused or made public. Your Name Your Email Your Phone Number 1. Do you ever experience shortness of breath or have trouble breathing? Yes No 2. Do you ever hear a 'wheezing' sound when you breathe? Yes No 3. Do you have a cough that won't go away? Yes No 4. Do you suffer from recurrent chest infections? Yes No 5. Do you ever have chest discomfort or pain when breathing in or out? Yes No 6. Do you feel a decreased ability to exercise due to your breathing? Yes No 7. Do you suffer from any allergies? Yes No 8. Are you a smoker (or ex-smoker)? Yes No 9. Do you ever cough up blood or mucus? Yes No 10. Have you ever been told that you have any of the following conditions: Asthma, Bronchitis, Bronchiectasis, COPD, Emphysema or Lung Cancer? Yes No 11. Do you currently (or in the past) work with asbestos? Yes No 12. Your gender Female Male Other 13. Your post code 14. Do you provide consent for one of Siesta Sleep & Respiratory's health professionals to contact you in response to this lung function assessment? Yes No Time is Up! Time's up