Subglottic Stenosis 6 Question Survey (SSS-6)

Please indicate which of the five responses below best describes your level of breathlessness over the past week. *

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.

Select the option that best matches your breathing these days

I have difficulty catching my breath *

On average during the past week, how much of the time did you cough? *

My Voice difficulties restrict my personal and social life. *

In general would you say your health is *

On average, during the past week, how limited were your moderate physical activities (such as walking, housework, carrying things) because of your breathing problems: *

Name *

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DOB *

Email *

Phone number

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Select the option that best matches your breathing these days

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