Asthma Screening Questionnaire

Thank you for your interest in learning more about our clinical research opportunities. See if you may qualify by answering a few short questions. By filling out the interest form below, you consent to being contacted by our patient enrollment specialists via phone, text, or email with more information.

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Camp ID

First Name

Last Name

Select Gender

Gender

Date of Birth

Date

Language

Current Date

Date

Age

Primary Phone Number

Please enter a valid phone number.Format: (000-000-0000).

Secondary Phone Number

Please enter a valid phone number.Format: (000-000-0000).

Email

example@example.com

Metro Area

Zip Code

Metro Code

State ID

CampRefID

Race

Ethnicity

Weight

Feet

Inches

Calculated BMI

Have you been diagnosed with asthma for at least 3 months?

Is the individual currently utilizing any of the following medications for asthma MGMT? (Select all that apply)

Has the individual experienced an asthma exacerbation (defined as a hospital visit or systemic steroid use) within the last 6 months? (Select all that apply)

Is the individual a current smoker?

Eligibility Status