COPD Study Questionnaire
This is generalized patient questionnaire for Chronic Obstructive Pulmonary Disease (COPD) clinical research studies is essential for gathering consistent and relevant data from participants.
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Age
*
Sex
*
Doctor Name
First Name
Last Name
Doctor Practice Name
Doctor Phone
Please enter a valid phone number.
Have you ever been diagnosed with COPD?
*
Yes
No
If yes, when were you diagnosed?
-
Month
-
Day
Year
Date
What stage of COPD have you been diagnosed with?
*
Stage I (Mild)
Stage II (Moderate)
Stage III (Severe)
Stage IV (Very Severe)
Do you have any other respiratory conditions?
*
Yes
No
If, yes (please specify)
By submitting your personal identifying information through this form, you acknowledge and agree to the following: The information you provide will be used solely for the purpose of qualifying you for a clinical trial and your information will be handled in accordance with our Privacy Policy. You are not required to submit any information, but doing so may be necessary to receive certain services or information. We will not sell, trade, or rent your personal information to third parties.
*
Submit
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