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MALE QUESTIONNAIRE - PAGE 6(a)  You are on page 6(a) of 9 >     This section deals with chest discomfort. 643.  Do you experience chest pain? Do not include pressure or tightness. No / don't know Yes, I can touch the tender area Yes, it is deep in my chest Yes, it radiates to back, neck, jaw or arm 644.  If you experience chest pain, how would you rate its severity? Not applicable / don't know A minor sensation Significant Very significant Severe, almost unbearable 645.  Do you experience pain when breathing? Don't know No In the past only Mild discomfort Moderate / severe pain 646.  If you experience chest pain, how is it affected by breathing? Don't know The pain is unrelated to breathing It is worse only when I breathe in deeply It is worse only when I breathe out deeply It is worse when I breathe in or out 647.  Do you tend to get or have problems with chest pressure? Do not include pain or tightness. Don't know No Occasionally / moderately Often / severely 648.  Do you experience tightness in your chest? Do not include pain or pressure. Don't know No Rarely Frequently Most of the time 649.  Have you had an aching or burning sensation behind your breastbone (top-middle chest)? Never had it / don't know Probably had it/minor episode(s) now resolved Major episode(s) now resolved Current minor problem Current major problem Add any additional information here for the questions above: Please mention the question number(s) if possible.

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