BREATHE-3 Patient Screener

1

Have you been told by a doctor that you have emphysema or COPD?* This field is required.

Yes

No

Not sure

2

Do you currently see a pulmonologist (a lung specialist)?* This field is required.

Yes

No

Not sure

3

Do you currently smoke or vape?* This field is required.

Yes

No — I quit within the past 4 months

No — I quit more than 4 months ago

No — I've never smoked

4

Are you currently being treated for cancer?* This field is required.

Yes

No

5

How far can you usually walk on flat ground before you have to stop to catch your breath?* This field is required.

Less than one block

About one block

About two blocks

Three or more blocks

6

Height (feet)* This field is required.

7

Height (inches)* This field is required.

8

Weight (pounds)* This field is required.

9

BMI (auto-calculated)

10

How old are you?* This field is required.

Under 40

40–64

65–84

85 or older

11

In the past 12 months, have you had any of these tests?* This field is required.PLEASE SELECT ALL THAT APPLY

CT scan or X-Ray of your lungs

A breathing test where you breathed into a tube (pulmonary function test)

A breathing test where you sat inside a clear booth (body box / plethysmography)

None of these or not sure

12

Do your lungs feel over-inflated, like your chest is too full of air and you cannot fully catch your breath?* This field is required.

Often

Sometimes

Never

Not sure

13

Do you currently use supplemental oxygen at home?* This field is required.

Yes

No

14

Have you participated in any pulmonary rehabilitation in the past 12 months?* This field is required.

Yes

No

Not sure

15

Please list all the medications you take regularly for your breathing condition, including inhalers, pills, and anything for your heart or other conditions.Names are best, but describe them however you can. Short, plain-language answers are fine.

16

Have you ever had surgery on your lungs or any procedure on your lungs?* This field is required.

Yes

No

Not sure

17

What procedure did you have done, and roughly when was it?For example, surgery to remove part of a lung, a lung transplant, or having valves placed in your airways.

18

Do you have any other significant health conditions? Please describe.For example, a heart attack or stroke, heart problems, diabetes, kidney or liver problems, or another lung condition such as asthma.

19

Have you ever been told you do not qualify for a lung valve procedure (sometimes called Zephyr valves)?* This field is required.

Yes

No

Not sure

20

Do you recall the reason you were told you did not qualify? Please share.

21

To proceed, please provide your contact information. The study site nearest you will contact you for further screening.

22

Full Name* This field is required.

First Name

Last Name

23

Email address* This field is required.

example@example.com

24

Phone number* This field is required.

Please enter a valid phone number.

25

ZIP code* This field is required.

26

Please select the study location within a comfortable driving distance for you* This field is required.The BREATHE-3 study is currently offered at a limited number of locations. We apologize if there is not one near you.

Phoenix, AZ

Birmingham, AL

Kansas City, MO

Pennsylvania (statewide)

None of these locations are within a 5-hour drive of me

27

I have read and agree to the statement above.* This field is required.By submitting this form, I confirm that: the information I've given is accurate to the best of my knowledge; I understand this is a short questionnaire to help see whether the BREATHE-3 research study might be a fit for me, that it is not enrollment in the study, and it does not guarantee I will qualify or be contacted; I give permission for the study team and the participating research site nearest me to review the health and contact information I've provided, and to use it to decide whether to reach out to me; I agree the study team may contact me by phone, email, or text message at the details I've provided (message and data rates may apply; reply STOP to opt out of texts); I understand that taking part is completely voluntary, that I can stop at any time, and that choosing not to take part will not affect my regular medical care; and my information will be kept secure and handled as described in the Privacy Policy.

I have read and agree to the statement above.

28

Referrer

29

Page URL

30

Lead Score

31

Outcome

32

User-ID

33

Submission Date

Date