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Asthma Case Collection
*
1.
Are you currently in clinical practice?
(Required.)
Yes
No
*
2.
How many patients with poorly controlled or difficult-to-treat asthma do you see on a weekly basis?
(Required.)
0
1-5
6-10
>10
*
3.
The remaining questions are regarding your patient case.
Please indicate your patient’s sex:
(Required.)
Male
Female
*
4.
Please indicate your patient’s age group:
(Required.)
0-5 years
6-11 years
12-17 years
≥18 years
*
5.
Does the patient have any of the following comorbidities? (Choose all that apply)
(Required.)
Atopic dermatitis
Food allergy
Allergic rhinitis
*
6.
How would you classify your patient’s asthma phenotype?
(Required.)
Eosinophilic
Neutrophilic
Mixed eosinophilic/neutrophilic
Allergic
Unknown
*
7.
How would you classify your patient’s endotype?
(Required.)
Th2 high
Th2 low
Unknown
*
8.
Is the patient currently on a biologic?
(Required.)
Yes
No
*
9.
Please provide a detailed description of your case, including past and current medication, relevant comorbidities, known laboratory values, and clinical assessment:
(Required.)
*
10.
If my case is selected for discussion, I can be contacted to provide additional HIPAA-compliant details, if necessary, to help elucidate the scenario for resolution by the expert faculty:
(Required.)
Yes
No
11.
If yes, please provide the best contact method and information to reach you.
Current Progress,
0 of 11 answered
