COPD Study Survey

Please complete this short survey to see if you qualify to participate in this study.

Question Title

* 1. Please leave your name, phone number, and email for us to contact you should you qualify for this trial.

Name:

Phone #:

Email:

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* 2. Are you at least 40 years old?

Yes

No

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* 3. Have you had a COPD diagnosis for at least 12 months?

Yes

No

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* 4. Do you have any symptoms such as cough, mucus in chest, chest tightness, breathlessness, or lack of energy?

Yes

No

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* 5. Have you had worsening symptoms requiring medications, hospitalization, or an ER visit?

Yes

No

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* 6. Do you take a daily inhaled medication for your COPD?

Yes

No

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* 7. Do you require more than 15 hours of oxygen therapy each day?

Yes

No