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Severe Asthma Study Survey
Please complete this short survey to see if you qualify to participate in this study.
1.
Please leave your name, phone number, and email for us to contact you should you qualify for this trial.
Name:
Phone #:
Email:
2.
Are you between 18 and 70 years old?
Yes
No
3.
Have you been diagnosed with asthma requiring a high-dose inhaler with additional drug therapy?
Yes
No
4.
Do you have a history of high blood eosinophils?
Yes
No
I don't know
5.
Have you ever been diagnosed with COPD, pulmonary fibrosis, or hypoventilation syndrome?
Yes
No
6.
Do you smoke cigarettes, use e-cigarettes, or smoke marijuana currently?
Yes
No
7.
Do you take immunosuppressive medications like methotrexate, troleandomycin, or chronic systemic corticosteroids?
Yes
No
I'm not sure.