Diagnosed medical conditions national Survey

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1. Please complete the contact information below.

First and Last Name:

Address:

City/Town:

State:

ZIP:

Email Address:

Phone Number:

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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)

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3. How old are you?

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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)

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5. Has a doctor formally diagnosed this person with asthma?

Yes

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6. How old is the person whom you care for?

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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)

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8. Are you the main person who provides care for this person?

Yes

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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

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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?

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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

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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

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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

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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

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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?

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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)

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17. PATIENTS- What dose of the medication(s) do you take? (example: 50 mcg/500mcg)
CAREGIVERS- Same question.

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18. How many times a day do you take the medication?

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19. How many puffs/inhalations do you take each time?

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20. What is your gender?

Male

Female

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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

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22. What is the highest level of education you have completed?

Some high school

High school graduate

Some college

College graduate or more

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23. Which of the following best describes your marital status?

Married or living with partner

Divorced or separated

Widowed

Single, never married

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24. Which of the following best describes your current employment status?

Employed full-time

Employed part-time

Unemployed

Retired

Other (please specify)

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25. What is your overall annual household income?

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26. Will you be able to access the internet for your interview?

Yes

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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)

Occupation:

Company:

Industry:

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1. Please complete the contact information below.

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2. Has a doctor diagnosed you with any of the following?

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3. How old are you?

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4. Do you care for someone who has been diagnosed with any of the following?

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5. Has a doctor formally diagnosed this person with asthma?

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6. How old is the person whom you care for?

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7. What is your relationship to this person?

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8. Are you the main person who provides care for this person?

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9. Which of the following activities do you do for this person?

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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?

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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…)?

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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?

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13. [PATIENTS] How often do you use a rescue inhaler?[CAREGIVERS] How often does this person use a rescue inhaler?

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14. [PATIENTS] How much do your asthma symptoms limit your daily activities?[CAREGIVERS] How much do asthma symptoms limit the person’s daily activities?

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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?

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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?

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17. PATIENTS- What dose of the medication(s) do you take? (example: 50 mcg/500mcg)CAREGIVERS- Same question.

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18. How many times a day do you take the medication?

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19. How many puffs/inhalations do you take each time?

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20. What is your gender?

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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?

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22. What is the highest level of education you have completed?

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23. Which of the following best describes your marital status?

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24. Which of the following best describes your current employment status?

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25. What is your overall annual household income?

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26. Will you be able to access the internet for your interview?

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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)

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…)?

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?

13. [PATIENTS] How often do you use a rescue inhaler?
[CAREGIVERS] How often does this person use a rescue inhaler?

14. [PATIENTS] How much do your asthma symptoms limit your daily activities?

[CAREGIVERS] How much do asthma symptoms limit the person’s daily activities?

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?

17. PATIENTS- What dose of the medication(s) do you take? (example: 50 mcg/500mcg)
CAREGIVERS- Same question.

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)