Medical Research Council Questionnaire

A medical research council questionnaire is a document which is created and composed by the Medical Research Council in the United Kingdom seeking to underline and extricate information about respiratory distress experienced by people. The forms are provided to specific patients, generally periodically, and they are requested to fill in the form. The answers provided to the specific and incisive questions in the Medical Research Council Questionnaire are such that they enable medical practitioners to make a primary diagnosis. Such a questionnaire should be designed according to the predesigned layout provided by the MRC.

Sample Medical Research Council Questionnaire:

Name of patient/individual: _______________________________________

Preliminary diagnoses made: _______________________________________

Supervising doctor: ______________________________________

Q1. Do you often feel breathless or short of breath during strenuous activity?

____________________________________

Q2. What kind of activity among the one motioned below cause shortness of breath?

Brushing hair
Running
Stretching
Climbing stairs

Q3. Have you ever had any previous history of asthma and/or bronchitis which may have led to a decreased lung capacity?

Yes, I have had prior history of these ailments
No, I have never been diagnosed with one or the other

Q4. Are you exposed to a high pollution environment on a daily basis [leaving apart our natural surroundings]? If yes, mention the nature of the environment and why you are exposed to it.

________________________________________

Q5. Have you been subjected to any major or minor surgeries in the recent past?

______________________________________

Q6. Do you smoke frequently? If yes, what is your daily intake as far as nicotine is concerned?

_______________________________________________