Diagnosed Medical Conditions- COPD/ ASTHMA

1.

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1. Please complete the contact information below.

First and Last Name:

Address:

City/Town:

State:

ZIP:

Email Address:

Phone Number:

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2. What is your gender?

Male

Female

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3. What is your current age?

a. Under 18

b. 18-24

c. 25-34

d. 35-49

e. 50-64

f. Over 65

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4. What is your ethnicity?

Caucasian

African American / Black

Asian

American Indian / Native American

Hispanic / Latino

Other (please specify)

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5. What is the highest level of education you have completed?

Some high school

Graduated high school

Some college

Graduated college

Some graduate school

Earned graduate degree

Other (please specify)

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6. What is your current work status?

Full-Time Employed

Part-Time Employed

Homemaker

Unemployed / Looking for work

Retired

Student Full-Time

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7. Please let us know which one you have a CURRENT diagnosis of.
( please select all that apply.)

COPD ( current diagnosis)

Asthma ( current diagnosis)

Hereditary Angioedema- HAE

Metastatic Melanoma

Uterine Fibroids

Diabetes

Cancer

Other (please specify)

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8. If you ave been diagnosed with COPD or Asthma, Which of the following medication/s are you prescribed and have been actively taking for 3 months? If more than one, please indicate.

Symbicort 80/4.5

Symbicort 160/4.5

Advair 250/50

Advair 500/50

Breo 100/25

Breo 200/25

Spririva Respimat 2.5

Spiriva Respimat 5

Spiriva Handihaler 18

Incruse 62.5

Tudorza 400

Anoro 55/22

Bevespi 18/ 9.6

Stiolto 2.5

Utibron Neohaler 27.5 /15.6

Other (please specify)

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9. If you have been diagnosed with COPD, Do you know your CAT score?

Yes

I do not know

I do not have COPD

If you do know your cat score, please provide us that here.

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10. If you have been diagnosed with COPD, have you had at least two exacerbations, or one COPD-related hospitalization, in the past 12 months?

Yes, I have experienced two exacerbations or one COPD related hospitalization, in the past 12 months.

No, I have NOT experienced two exacerbations or one COPD related hospitalization, in the past 12 months.

I do not have COPD.

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11. Do you have a cognitive impairment, hearing difficulty, visual impairment, acute psychopathology, or insufficient knowledge of English, which in the opinion of the investigator/interviewer, could interfere with the patient’s ability to provide written consent and complete the focus group?

Yes

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12. Do you have a known respiratory disorders other than COPD or Asthma, including active tuberculosis, lung cancer, bronchiectasis, sarcoidosis, lung fibrosis, pulmonary hypertension, and interstitial lung disease

Yes

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13. Do you have a current diagnosis of organic heart disease with resultant left ventricular failure and NYHA class 2-4?

Yes

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14. Do you have a known neuromuscular disease?

Yes

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15. Do you have a simultaneous process that can result in significant dyspnea independent of COPD/ ASTHMA , including but not limited to severe anemia?

Yes

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16. On a scale from 1-10 how do you rate your condition (1 being mild symptoms and 10 being extreme symptoms?)

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17. Are you willing to participate in an in-person focus group?
In Chicago-Downtown/ Ontario St or NYC- Manhattan/5th area?

Yes

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1. Please complete the contact information below.

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2. What is your gender?

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3. What is your current age?

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4. What is your ethnicity?

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5. What is the highest level of education you have completed?

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6. What is your current work status?

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7. Please let us know which one you have a CURRENT diagnosis of. ( please select all that apply.)

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8. If you ave been diagnosed with COPD or Asthma, Which of the following medication/s are you prescribed and have been actively taking for 3 months? If more than one, please indicate.

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9. If you have been diagnosed with COPD, Do you know your CAT score?

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10. If you have been diagnosed with COPD, have you had at least two exacerbations, or one COPD-related hospitalization, in the past 12 months?

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11. Do you have a cognitive impairment, hearing difficulty, visual impairment, acute psychopathology, or insufficient knowledge of English, which in the opinion of the investigator/interviewer, could interfere with the patient’s ability to provide written consent and complete the focus group?

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12. Do you have a known respiratory disorders other than COPD or Asthma, including active tuberculosis, lung cancer, bronchiectasis, sarcoidosis, lung fibrosis, pulmonary hypertension, and interstitial lung disease

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13. Do you have a current diagnosis of organic heart disease with resultant left ventricular failure and NYHA class 2-4?

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14. Do you have a known neuromuscular disease?

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15. Do you have a simultaneous process that can result in significant dyspnea independent of COPD/ ASTHMA , including but not limited to severe anemia?

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16. On a scale from 1-10 how do you rate your condition (1 being mild symptoms and 10 being extreme symptoms?)

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17. Are you willing to participate in an in-person focus group? In Chicago-Downtown/ Ontario St or NYC- Manhattan/5th area?

7. Please let us know which one you have a CURRENT diagnosis of.
( please select all that apply.)

17. Are you willing to participate in an in-person focus group?
In Chicago-Downtown/ Ontario St or NYC- Manhattan/5th area?