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Diagnosed medical conditions national
2.
1.
Please complete the contact information below.
(Required.)
First and Last Name:
Address:
City/Town:
State:
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
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HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP:
Email Address:
Phone Number:
2.
Has a doctor diagnosed you with any of the following?
High blood pressure (hypertension)
Type 2 diabetes
High cholesterol
COPD
Asthma
Allergic Rhinitis
Other (please specify)
3.
How old are you?
4.
Do you care for someone who has been diagnosed with any of the following?
High blood pressure (hypertension)
Type 2 diabetes
High cholesterol
COPD
Asthma
Allergic Rhinitis
Other (please specify)
5.
Has a doctor formally diagnosed this person with asthma?
Yes
No
6.
How old is the person whom you care for?
7.
What is your relationship to this person?
This person is my child / step-child / adopted child
This person is my sibling
This person is my relative (specify relation: ______ )
I am a professional care giver
Other (please specify)
8.
Are you the main person who provides care for this person?
Yes
No
9.
Which of the following activities do you do for this person?
Accompany on doctor visits
Discusses treatment options with this person’s physician
Help make treatment decision
Help take medication
Discuss his / her health on a regular basis
10.
PATIENTS] At what age did a doctor first diagnose you with asthma?
[CAREGIVERS] At what age did a doctor first diagnose this person with asthma?
11.
[PATIENTS] How often do you experience asthma symptoms (e.g. coughing, wheezing, difficulty breathing, chest tightness, etc…)?
[CAREGIVERS] How often does this person experience asthma symptoms (e.g. coughing, wheezing, difficulty breathing, chest tightness, etc…)?
>2 days a week, but not daily
Daily
Throughout the day
12.
[PATIENTS] How often do you wake up at night because of your asthma symptoms?
[CAREGIVERS] How often does this person wake up at night because of asthma symptoms?
3 – 4 times a month
>1 time a week, but not nightly
Often 7 times a week
13.
[PATIENTS] How often do you use a rescue inhaler?
[CAREGIVERS] How often does this person use a rescue inhaler?
>2 days a week, but not daily and not more than once on any day
Daily
Several times a day
14.
[PATIENTS] How much do your asthma symptoms limit your daily activities?
[CAREGIVERS] How much do asthma symptoms limit the person’s daily activities?
Minor limitations
Some limitations
Extreme limitations
15.
[PATIENTS] How many times have you used an oral systemic corticosteroid (e.g. prednisone) in the last 12 months?
[CAREGIVERS] How many times has the person used an oral systemic corticosteroid (e.g. prednisone) in the last 12 months?
16.
[PATIENTS] For the next few questions, please have your asthma medications on hand. Which medications are you currently taking to treat asthma?
[CAREGIVERS] For the next few questions, please have the person’s asthma medications on hand. Which medications does the person take to treat asthma?
Advair [US] Seretirde [UK], Viani [Germany] (salmeterol + fluticasone)
Symbicort® (formoterol + budesonide)
Dulera® (formoterol + mometasone)
Flovent Diskus [US], Flixotide [UK] (fluticasone)
Flovent Flovent HFA [US], Flixotide [UK] (fluticasone)
Pulmicort Flexhaler/ Easyhaler® Budesonide (budesonide)
Pulmicort Turbohaler (budesonide)
Asmanex / Nasonex (mometasone)
Qvar [US and UK], Pulvinal Beclometasone Inhaler [UK], Ventolair / Junik/ Sanasthmax/ INUVAIR [Germany] (beclomethasone)
Alvesco (ciclesonide)
Serevent®: Serevent Diskus® [US], Serevent Diskhaler® [UK]
Foradil®/ Foradil® Aerolizer, Oxis Turbohaler [UK and Germany], Formatris Novolizer [Germany] (formoterol)
Albuterol
Xopenex®/ Xopenex HFA® (Levalbuterol)
Proventil
Ventolin
ProAir
Xolair®(omalizumab)
Combivent® (albuterol + Ipratropium bromide)
Singulair® (montelukast sodium)
Prednisone
Not sure
No prescription medications for asthma
Other (please specify)
17.
PATIENTS- What dose of the medication(s) do you take? (example: 50 mcg/500mcg)
CAREGIVERS- Same question.
18.
How many times a day do you take the medication?
19.
How many puffs/inhalations do you take each time?
20.
What is your gender?
Male
Female
21.
Are you or anyone in your family affiliated in any way with any of the following on a full time or part time basis: government department of health, a pharmaceutical or biotech manufacturing company; a market research, public relations, advertising firm, or healthcare consulting firm?
Yes
No
22.
What is the highest level of education you have completed?
Some high school
High school graduate
Some college
College graduate or more
23.
Which of the following best describes your marital status?
Married or living with partner
Divorced or separated
Widowed
Single, never married
24.
Which of the following best describes your current employment status?
Employed full-time
Employed part-time
Unemployed
Retired
Other (please specify)
25.
What is your overall annual household income?
26.
Will you be able to access the internet for your interview?
Yes
No
27.
What is your Occupation-Job Title, Company you work for, and Industry?
(If you are Retired, Unemployed or a Homemaker Please tell us your previous employment information. If you are a full-time student please enter your Grade, School and Major)
(Required.)
Occupation:
Company:
Industry:
