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COPD 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 at least 40 years old?
Yes
No
3.
Have you had a COPD diagnosis for at least 12 months?
Yes
No
4.
Do you have any symptoms such as cough, mucus in chest, chest tightness, breathlessness, or lack of energy?
Yes
No
5.
Have you had worsening symptoms requiring medications, hospitalization, or an ER visit?
Yes
No
6.
Do you take a daily inhaled medication for your COPD?
Yes
No
7.
Do you require more than 15 hours of oxygen therapy each day?
Yes
No