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the following? \(Please circle your replies\))Tj 1.5 -2.186 Td [(sneezing)-7240(blocked nose )]TJ 11.243 -1.2 Td (or congestion)Tj 11.243 1.2 Td [(watery nose)-5851(shortness of breath)]TJ -22.485 -3.428 Td [(wheezing)-7017(chest tightness)-4572(cough)-8518(sputum \(phlegm\))]TJ 0 -2.228 TD [(coughing at night)-3625(severe itching)-5073(severe swelling)-4406(acid stomach / )]TJ 33.728 -1.2 Td (heartburn)Tj -33.728 -2.228 Td (dif)Tj /TT2 1 Tf (\336)Tj /TT1 1 Tf 1.306 0 Td [( )28(culty breathing)-3182(rash)-9297(chest pain)-6684(frequent fevers)]TJ -2.806 -3.667 Td (Have you been told, or do you suspect you have any of the following? \(P\ lease circle your replies\))Tj 1.5 -2.186 Td [(sinusitis)-7693(ear infections)-5302(nasal polyps)-5691(chronic bronchitis)]TJ T* [(eczema)-7748(hives)-8915(stomach re)]TJ /TT2 1 Tf 27.446 0 Td (\337)Tj /TT1 1 Tf 0.25 0 Td [( )28(ux)-4748(allergic rhinitis / )]TJ 6.054 -1.2 Td (hay fever)Tj -33.75 -2.228 Td [(pneumonia)-6302(asthma)-7971(frequent 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-0.074 l 0 0 l f Q EMC EMC BT 0 0 0 0.25 k /GS1 gs /TT0 1 Tf 0.0278 Tw 7 0 0 7 423.187 768.9038 Tm [(P)74(A)74(TIENT IDENTIFICA)74(TION )37(AREA)]TJ /CS0 cs 1 scn /GS0 gs 12 0 0 12 54 702.6137 Tm (Aspirin Exacerbated Respiratory Disease \(AERD\)/)Tj 0 -1.167 TD [(Samter)-37(\222)37(s T)55(riad Patient Questionnaire)]TJ /TT1 1 Tf 7 0 0 7 54 18 Tm (Page 5 of 6)Tj ET q 1 0 0 1 54 637.16 cm /CS0 CS 1 SCN 0.5 w /GS3 gs 0 0 m 540 0 l S Q q 1 0 0 1 54 608.66 cm /CS0 CS 1 SCN 0.5 w /GS3 gs 0 0 m 540 0 l S Q q 1 0 0 1 54 512.024 cm /CS0 CS 1 SCN 0.5 w /GS3 gs 0 0 m 540 0 l S Q q 1 0 0 1 54 484.124 cm /CS0 CS 1 SCN 0.5 w /GS3 gs 0 0 m 540 0 l S Q q 1 0 0 1 54 456.624 cm /CS0 CS 1 SCN 0.5 w /GS3 gs 0 0 m 540 0 l S Q q 1 0 0 1 54 360.751 cm /CS0 CS 1 SCN 0.5 w /GS3 gs 0 0 m 540 0 l S Q q 1 0 0 1 54 304.351 cm /CS0 CS 1 SCN 0.5 w /GS3 gs 0 0 m 540 0 l S Q q 1 0 0 1 54 276.451 cm /CS0 CS 1 SCN 0.5 w /GS3 gs 0 0 m 540 0 l S Q q 1 0 0 1 54 116.02 cm /CS0 CS 1 SCN 0.5 w /GS3 gs 0 0 m 540 0 l S Q q 1 0 0 1 54 92.62 cm /CS0 CS 1 SCN 0.5 w /GS3 gs 0 0 m 540 0 l S Q q 1 0 0 1 54 69.22 cm /CS0 CS 1 SCN 0.5 w /GS3 gs 0 0 m 540 0 l S Q q 1 0 0 1 54 45.82 cm /CS0 CS 1 SCN 0.5 w /GS3 gs 0 0 m 540 0 l S Q BT /GS3 gs /TT1 1 Tf 0 Tw 12 0 0 12 54 639.41 Tm [(Do you drink alcohol: )-2384(Y)92(es )-1091(No)]TJ 0 -2.375 TD (Do you ever have any of the following when you drink alcohol \(please ci\ rcle\):)Tj 1.5 -2.186 Td [(Stuf)18(fy nose/nasal congestion)-2982(Runny nose)-3288(Shortness of breath)-3272(Wheezing)]TJ /TT0 1 Tf -1.5 -3.542 Td (Environmental History)Tj /TT1 1 Tf 0 -2.325 TD [(What type of home do you live in? )-5658(house )-4498(apartment )-3470(multifamily)]TJ T* [(Location of home: )-9772(city )-5722(suburb )-4165(rural)]TJ 0 -2.375 TD (What kind of air control and heating does the home have? \(Please circle\ your replies\):)Tj 1.5 -2.186 Td [(forced hot water)-3376(forced hot air)-4710(humidi)]TJ /TT2 1 Tf 24.04 0 Td (\336)Tj /TT1 1 Tf 0.25 0 Td [( )28(er)-5509(room air 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3.204 0.5 3.649 1.19 3.649 c 1.569 3.649 2.063 3.566 2.371 3.399 c 2.398 3.37 l 2.338 3.138 2.338 3.027 2.31 2.442 c 2.282 2.415 l 2.124 2.415 l 2.099 2.442 l 2.045 2.907 l 2.035 2.981 1.737 3.37 1.119 3.37 c 0.687 3.37 0.229 3.102 0.229 2.544 c 0.229 2.108 0.484 1.923 1.014 1.812 c 1.605 1.691 l 2.16 1.58 2.609 1.468 2.609 0.688 c 2.609 -0.047 2.054 -0.807 0.756 -0.807 c 0.336 -0.807 0.009 -0.716 -0.285 -0.604 c -0.309 -0.575 l -0.294 -0.361 -0.257 0.029 -0.247 0.465 c -0.223 0.491 l -0.047 0.491 l -0.019 0.465 l 0 0 l f Q q 1 0 0 1 173.935 733.586 cm 0 0 0 1 k /GS2 gs 0 0 m 0 0.891 -0.008 2.868 -1.2 2.868 c -2.267 2.868 -2.417 1.494 -2.417 -0.15 c -2.417 -1.451 -2.258 -3.056 -1.191 -3.056 c -0.034 -3.056 0 -1.198 0 0 c h -3.016 -0.084 m -3.016 2.635 -1.871 3.146 -1.129 3.146 c 0.602 3.146 0.635 0.946 0.635 0.082 c 0.635 -0.91 0.486 -3.334 -1.271 -3.334 c -3.016 -3.334 -3.016 -1.022 -3.016 -0.084 c f Q q 1 0 0 1 175.216 730.642 cm 0 0 0 1 k /GS2 gs 0 0 m 0.363 0.389 l 2.444 2.638 2.859 3.194 2.859 4.15 c 2.859 4.996 2.391 5.488 1.678 5.488 c 1.155 5.488 0.734 5.172 0.697 5.126 c 0.626 5.005 0.468 4.42 0.398 4.187 c 0.371 4.159 l 0.194 4.159 l 0.168 4.187 l 0.239 4.586 0.3 5.07 0.327 5.497 c 0.353 5.534 l 0.511 5.664 1.094 6.091 1.809 6.091 c 2.885 6.091 3.521 5.365 3.521 4.373 c 3.521 3.761 3.254 3.065 2.022 1.773 c 0.661 0.354 l 2.34 0.354 l 3.152 0.354 3.539 0.381 3.829 0.418 c 3.856 0.389 l 3.838 0.298 3.829 0.196 3.829 0.066 c 3.829 -0.056 3.838 -0.168 3.856 -0.25 c 3.829 -0.278 l 3.212 -0.27 2.593 -0.25 1.986 -0.25 c 1.324 -0.25 0.661 -0.27 0.026 -0.278 c 0 -0.25 l 0 0 l f Q q 1 0 0 1 181.446 735.926 cm 0 0 0 1 k /GS2 gs 0 0 m 0 0.139 -0.009 0.167 -0.045 0.167 c -0.079 0.167 -0.282 0.073 -0.484 -0.039 c -1.519 -0.595 l -1.561 -0.566 l -1.58 -0.428 -1.607 -0.261 -1.607 -0.206 c -1.607 -0.15 -1.589 -0.131 -1.156 0.028 c -0.558 0.25 0.221 0.658 0.59 0.891 c 0.688 0.807 l 0.646 0.538 0.636 0.25 0.636 -0.362 c 0.636 -4.449 l 0.636 -5.116 0.688 -5.155 0.757 -5.2 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IDENTIFICA)74(TION )37(AREA)]TJ /CS0 cs 1 scn /GS0 gs 12 0 0 12 18 702.6137 Tm (Aspirin Exacerbated Respiratory Disease \(AERD\)/)Tj 0 -1.167 TD [(Samter)-37(\222)37(s T)55(riad Patient Questionnaire)]TJ /TT1 1 Tf 7 0 0 7 18 18 Tm (Page 6 of 6)Tj ET q 1 0 0 1 18.36 637.16 cm /CS0 CS 1 SCN 0.5 w /GS3 gs 0 0 m 540 0 l S Q q 1 0 0 1 18.36 613.76 cm /CS0 CS 1 SCN 0.5 w /GS3 gs 0 0 m 540 0 l S Q q 1 0 0 1 18.36 576.86 cm /CS0 CS 1 SCN 0.5 w /GS3 gs 0 0 m 540 0 l S Q q 1 0 0 1 18.36 539.06 cm /CS0 CS 1 SCN 0.5 w /GS3 gs 0 0 m 540 0 l S Q q 1 0 0 1 18.36 515.66 cm /CS0 CS 1 SCN 0.5 w /GS3 gs 0 0 m 540 0 l S Q q 1 0 0 1 18.36 478.76 cm /CS0 CS 1 SCN 0.5 w /GS3 gs 0 0 m 540 0 l S Q q 1 0 0 1 18.36 455.36 cm /CS0 CS 1 SCN 0.5 w /GS3 gs 0 0 m 540 0 l S Q q 1 0 0 1 18.36 431.96 cm /CS0 CS 1 SCN 0.5 w /GS3 gs 0 0 m 540 0 l S Q q 1 0 0 1 18.36 395.06 cm /CS0 CS 1 SCN 0.5 w /GS3 gs 0 0 m 540 0 l S Q q 1 0 0 1 18.36 371.66 cm /CS0 CS 1 SCN 0.5 w /GS3 gs 0 0 m 540 0 l S Q q 1 0 0 1 18.36 348.26 cm /CS0 CS 1 SCN 0.5 w /GS3 gs 0 0 m 540 0 l S Q q 1 0 0 1 18.36 325.26 cm /CS0 CS 1 SCN 0.5 w /GS3 gs 0 0 m 540 0 l S Q q 1 0 0 1 18.36 287.36 cm /CS0 CS 1 SCN 0.5 w /GS3 gs 0 0 m 540 0 l S Q q 1 0 0 1 18.36 263.96 cm /CS0 CS 1 SCN 0.5 w /GS3 gs 0 0 m 540 0 l S Q q 1 0 0 1 117.757 184.539 cm /CS0 CS 1 SCN 0.879 w /GS3 gs 0 0 m 242.603 0 l S Q q 1 0 0 1 369.36 184.539 cm /CS0 CS 1 SCN 0.879 w /GS3 gs 0 0 m 75 0 l S Q q 1 0 0 1 455.36 184.539 cm /CS0 CS 1 SCN 0.879 w /GS3 gs 0 0 m 60.661 0 l S Q q 1 0 0 1 83.042 117.039 cm /CS0 CS 1 SCN 0.879 w /GS3 gs 0 0 m 475.318 0 l S Q q 1 0 0 1 18.36 63.039 cm /CS0 CS 1 SCN 0.879 w /GS3 gs 0 0 m 243.965 0 l S Q q 1 0 0 1 369.36 63.039 cm /CS0 CS 1 SCN 0.879 w /GS3 gs 0 0 m 75 0 l S Q q 1 0 0 1 455.362 63.039 cm /CS0 CS 1 SCN 0.879 w /GS3 gs 0 0 m 60.659 0 l S Q BT /GS3 gs /TT1 1 Tf 0 Tw 12 0 0 12 18.36 639.41 Tm [(Have you ever felt unsafe in the home or been afraid of anyone? )-926(Y)92(es )-1091(No)]TJ 0 -5.025 TD [(Do you feel pain as part of your daily life? )-2101(Y)92(es )-1091(No)]TJ 0 -1.95 TD (If yes, where do you feel pain? How does the pain start? How long does\ it last? How would you )Tj 0 -1.2 TD (describe it? )Tj 0 -5.025 TD (If yes, on a scale from 1-10, 10 being the greatest pain, which number b\ etter describes this pain?)Tj 0 -1.95 TD (If yes, how do you treat your pain? )Tj 0 -5.025 TD [(Have you had any unexpected weight gain or loss in the past six months? \ )-3147(Y)92(es )-1091(No)]TJ 0 -1.95 TD (How do you like to learn new information? )Tj /T1_0 1 Tf 21 0.083 Td (\002)Tj /TT1 1 Tf 0.986 -0.083 Td [( )18(T)111(alking with your nurse or doctor )]TJ /T1_0 1 Tf 17.014 0.083 Td (\002)Tj /TT1 1 Tf 0.986 -0.083 Td ( Reading)Tj -39.986 -1.95 Td [(Have you fallen down within the past year? )-1711(Y)92(es )-1091(No)]TJ 0 -5.075 TD [(Do you have a Health Care Proxy)74(, )55(Advance Directive, or Living Will? )-5283(Y)92(es )-1091(No)]TJ 0 -1.95 TD (If yes, please tell us his or her name: )Tj /TT2 1 Tf 0 -3.125 TD (The information on this form is accurate to the best of my knowledge. 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