COPD 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

SiteId

State ID

CampRefID

Race

Ethnicity

Weight

Feet

Inches

Calculated BMI

Has a doctor told you that you have COPD (chronic obstructive pulmonary disease) for at least 1 year?

In the past year, have you had a cough with mucus (phlegm) that lasted 3 months or longer?

In the past year, have you had a COPD flare-up that required any of the following? (Select all that apply)

Do you currently smoke, or have you smoked tobacco in the past?

Have you been taking prescription medication for COPD for at least 3 months?

Do you use oxygen at home for more than 12 hours each day and plan to continue using it?

Eligibility Status