Sub-glottic Stenosis Severity 6 (SSS-6) 1. Please indicate which of the five responses below best describes your level of breathlessness over the past week. (Choose only one response out of the five available below). I get short of breath only on strenuous exercise I get short of breath when hurrying on the level of climbing up a slight hill I walk slower than people of the same age on the level because of breathlessness, or have to stop for breath when walking at my own pace on the level. I stop for breath after walking 100 yards or after a few minutes on the level. I am too breathless to leave the house. 2. Please tick the box that best matches your breathing these days (Please select one answer only)Situation: I have difficulty catching my breath None Mild Moderate Severe 3. On average during the past week, how much of the time... (Please select one answer only)Situation: ..... did you cough? None Hardly ever A few times Several times Many times A great many times Almost all the time 4. Please mark which option best reflect your voice symptoms/difficulties. (Please select one answer only)Situation: My Voice difficulties restrict my personal and social life. None Almost Never Sometimes Almost Always Always 5. On average, during the past week, how limited were your moderate physical activities(such as walking, housework, carrying things) because of your breathing problems: (Please select one answer only) Not limited at all Very slightly limited Slightly limited Moderately limited Very limited Extremely limited Totally limited 6. In general would you say your health is (Please select one answer only) Excellent Very Good Good Fair Poor First Name Surname DOB Email Phone number Please contact me by email Please contact me by phone Time's up
