Patient ID: NOTE: format is RM2???????
Date of entry:
Date of birth:
Weight:
MRC score:

 

ST. GEORGE’S RESPIRATORY QUESTIONNAIRE (SGRQ)

This questionnaire is designed to help us learn much more about how your breathing
is troubling you
and how it affects your life. We are using it to find out
which aspects of your illness cause you most problems, rather than
what the
doctors and nurses think your problems are.

Please read the instructions carefully and ask if you do not understand anything. Do
not spend too long deciding about your answers.

 

FOR QUESTIONS 11-15 IF YOU FIND A QUESTION THAT DOES NOT APPLY
TO YOU THEN YOU SHOULD ANSWER 'FALSE'

PLEASE REMEMBER TO ENTER AN ANSWER TO ALL QUESTIONS APART
FROM q8 (Wheeze) and q10 (Employment) WHICH YOU CAN LEAVE
BLANK IF THEY DON'T APPLY IN YOUR CASE

FOR EACH QUESTION PLACE A TICK OR CROSS IN THE CORRESPONDING
SMALL CIRCLE TO THE LEFT
OF YOUR ANSWER

Before completing the rest of the questionnaire:

Please tick in one box to show how you describe
your current health:


 

 

 

 

 

 

 

 

1) Over the past 4 weeks, I have coughed:





2) Over the past 4 weeks, I have brought up phlegm (sputum):





3) Over the past 4 weeks, I have had shortness of breath:

4) Over the last year, I have had attacks of wheezing:

Most days a week



5) During the past 4 weeks, how many severe or very unpleasant attacks
of chest trouble have you had?





6) How long did the worst attack of chest trouble last?






7) Over the past 4 weeks, how many good days (with little chest trouble) have you had?


good days
good days
is good

8) If you have a wheeze, is it worse in the morning?



9) How would you describe your chest condition?





10) If you have ever had paid employment:



 

 

Please ensure that you answer the following questions true or false.
Please do not leave them blank

11) Questions about what activities usually make you feel breathless these days:

Sitting or lying still  
Getting washed or dressed   
Walking around the home  
Walking outside on the level   
Walking up a flight of stairs  
Walking up hills  
Playing sports or games  

12) More questions about your cough and breathlessness these days:

My cough hurts  
My cough makes me tired  
 
I get breathless when I bend over  
My cough or breathing disturbs my sleep  
 

13) Questions about other effects your chest trouble may have on you these days.

 
 
 
I feel that I am not in control of my chest problem  
I do not expect my chest to get any better  
 
Exercise is not safe for me  
 

 

 

14) Questions about your medication.

 
 
 
My medication interferes with my life a lot  
I take no medication  

15) Questions about how activities may be affected by your breathing.

 
 
 
Jobs such as housework take a long time, or I have to stop for rests  
 
 
My breathing makes it difficult to do things such as walk up hills, carry things up stairs, light gardening such as weeding, dance, play bowls or play golf  
 
 

16) We would like to know how your chest trouble usually affects your daily life:

 
 
 
 
 

17) Here is a list of other activities that your chest trouble may prevent you doing.
(You do not have to tick these, they are just to remind you of ways in which your
breathlessness may affect you):

  • Going for walks or walking the dog
  • Doing things at home or in the garden
  • Sexual intercourse
  • Going out to church, pub, club or place of entertainment
  • Going out in bad weather or into smoky rooms
  • Visiting family or friends or playing with children

Please write in any other important activities that your chest trouble may stop you doing:

Now would you tick in the box (one only) which you think best describes how your chest affects you:




Thank you for filling in this questionnaire.
Before you finish would you please check to see that you have answered all the questions.