Thank you for your interest in our upcoming study. Please fill out the following preliminary questions below. Once completed, if you qualify, we will follow up with you shortly after to discuss details and scheduling. If you do not qualify we will email you at the end of the project thanking you for your time and asking if you would be interested in future projects that you may qualify for.

If you have any questions please contact Maggie at 847-373-4104 or email maggie@lagripperesearch.com

Thank you!

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* 1. Please fill out the following contact information: 

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* 2. VIDEO CONSENT

These interviews will be video streamed, audiotaped and streamed over a secure channel. Those who are watching will be members of a research team who are interested in hearing thoughts and opinions. These recordings are confidential and will not be made public. These recordings will be used for research purposes only. Nothing you say during the interview will be linked to your name. Are you willing to be interviewed knowing this?

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* 3. ADVERSE EVENT CONSENT

We are now being asked to pass on to our client details of adverse events about individual patients or groups of patients and / or product complaints that are raised during the course of market research surveys. Although this is a market research survey, and what is contributed is treated in confidence, should you raise an adverse event and / or product complaint, we will need to report this even if it has already been reported by you directly to the company or the regulatory authorities. In such a situation you will be contacted to ask whether or not you are willing to waive the confidentiality given to you under the market research codes of conduct specifically in relation to that adverse event and / or product complaint. Everything else you contribute during the course of the survey will continue to remain confidential. Are you happy to proceed on this basis?

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* 4. And finally, we fully recognize that we are amidst a continually evolving COVID-19 outbreak in the US and that healthcare professionals (HCPs), patients, caregivers, and members of the public are concentrating on their own health and that of their families and communities.  We know that your time is valuable, and in no way should you feel obligated to participate in this research opportunity.

We completely understand if you need to reschedule your interview or cancel. 

Are you happy to proceed on this basis?

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* 5. What month and year were you born? What is your current age?

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* 6. What is your gender?

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* 7. Do you or does anyone in your immediate family work in any of the following occupations?

Select all that apply

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* 8. If you selected ANY of the above industries, please clarify who works there and what their job title is:

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* 9. Have you participated in any market research interviews, focus groups, consumer discussions, or clinical trial studies within the past month?

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* 10. What was the subject or topic of the market research interview, focus group, consumer discussion, or clinical trial study that you participated in within the past month?

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* 11. Which of the following conditions have you been diagnosed with by a doctor?

Select all that apply

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* 12. How long have you been diagnosed with the condition(s) listed above. If you selected more than one condition above, please specify how long you have been diagnosed with each.

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* 13. Are you currently being treated for any of the following conditions?

  Yes No N/A
Chronic Bronchitis
COPD
Emphysema

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* 14. Are you currently diagnosed with Asthma? 

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* 15. At what age were you first diagnosed with Asthma?

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* 16. Do you currently smoke?

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* 17. If you do not currently smoke, have you ever smoked? 

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* 18. If you have stopped smoking, when did you quit?

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* 19. If you have stopped smoking , for how long did you smoke?

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* 20. Do you currently use oxygen therapy to treat your (COPD/Chronic Bronchitis/Emphysema)? 

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* 21. Below is a list of medications. Please select the option that best describes your usage of each medication: 

  • Never used
  • Have used in the past, but not currently using
  • Currently using

  Never used Have used in the past, but not currently using Currently using 
ProAir HFA
Proventil HFA
Ventolin HFA
Xopenex HFA
Albuterol
Levalbuterol
Singulair
montelukast sodium
Alvesco (ciclesonide)
Armonair (fluticasone propionate)
Asmanex (mometasone fuorate)
Flovent (Diskus or HFA) (fluticasone propionate)
Pulmicort (budesonide)
QVAR (beclomethasone dipripionate)
Arnuity (fluticasone furoate)
Atrovent HFA (ipratropium)
Combivent Respimat
Duoneb
Incruse Ellipta
Spiriva (Handihaler or Respimat)
Theophylline (brand names:  Theo-24, Theo-Dur, Theochron, Quibron-T/SR)
Tudorza Pressair
Serevent Diskus
Arcapta Neohaler
Brovana
Foradil Aerolizer
Striverdi Respimat
Advair (Diskus or HFA)
AirDuo RespiClick
Breo Ellipta
Dulera HFA MDI
Symbicort HFA MDI
Wixela
Generic Fluticasone propionate/salmeterol inhaler
Anoro Ellipta
Bevespi Aerosphere
Stiolto Respimat
Utibron Neohaler
Trelegy

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* 22. How open would you be towards switching the medication you are currently using to treat your (COPD/CHRONIC BRONCHITIS/ EMPHYSEMA)?

1 - Not open 10 - Very open
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 23. Have you ever required additional medications such as oral steroids like prednisone or antibiotics because your symptoms or breathing worsened?

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* 24. How long ago did you require additional medications such as oral steroids like prednisone or antibiotics for breathing or (COPD/CHRONIC BRONCHITIS/EMPHYSEMA) related issues? If never, leave blank.

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* 25. Have you had to go to the emergency room because (COPD/CHRONIC BRONCHITIS/EMPHYSEMA) symptoms or breathing worsened?

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* 26. How long ago was your last emergency room visit for breathing or (COPD/CHRONIC BRONCHITIS/EMPHYSEMA) related issues?

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* 27. Were you hospitalized because your (COPD/CHRONIC BRONCHITIS/EMPHYSEMA) symptoms or breathing worsened?

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* 28. How long ago was your last hospitalization for breathing or (COPD/CHRONIC BRONCHITIS/EMPHYSEMA) related issues?

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* 29. Do you have a laptop or desktop computer to participate in the online session?

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* 30. Does your laptop or desktop computer have a webcam that is either built in or connected via USB?

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* 31. Do you have high speed internet and a telephone where you will be participating in the online session?

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* 32. Does your computer have Flash Player version 13.0 or higher?

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* 33. Do you have a Windows computer?

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* 34. If you have a Windows computer, does it have Windows 7 or higher?

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* 35. Do you have a Mac computer?

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* 36. If you have a Mac computer, does it have 10.7.4 or higher?

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* 37. Does your computer have one or more of the following internet browsers? (Internet Explorer 8 or higher, Google Chrome, Mozilla Firefox or Safari)

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* 38. You will be asked to participate in a 75-minute interview by phone to discuss your experiences in more detail. You will need to have access to a computer with speakers and the internet in order to participate in the interview. Support will be available if you have questions about using the online platform, but you will need to be able to use your web browser and navigate the screen yourself.

Do you feel comfortable participating in a phone interview that requires you to use the internet if you are invited to do so, as long as the interview can be conducted at a time that is convenient for you?

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* 39. Do you agree to testing your computer at least 24 hours prior to your scheduled interview to ensure that your system is working properly?

0 of 39 answered
 

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