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Research Intro
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 Survey Center
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No personal information, such as your name and address will be released
without your prior knowledge and approval.

 

 

 

 

 

Name
First Name
Last Name
M.I.
Address
City
Zip
State
Street
1. Are you willing to participate in a national study to find the genes that might put someone at risk
for developing COPD?
If Yes , how far are you willing to travel (only 1 trip needed) to participate in this study?
Phone
Email
Daytime: include area code (123)555-1234
If Yes , are you willing to have someone from the COPD Foundation contact you so you can learn about how to participate in this national study?
2. Are you willing to have the information in this questionnaire stored in a confidential database at
the COPD Foundation and at the National Jewish Medical and Research Center ?
Evening: include area code (123)555-1234
Genetic Epidemiology of
Chronic Obstructive Pulmonary Disease
The questions we are about to ask you will help us identify your characteristics as a possible candidate for the study. National Jewish Medical and Research Center and the COPD Foundation will not share this information with third parties. If you are not selected as a candidate for this study, you may be contacted in the future for other studies.
1. For the last two years, have you had a cough for at least three months per year?
2. For the last two years, have you brought up phlegm from your chest at least three months per year?
Lung Symptoms
1. Do you have COPD?
a. Who made this diagnosis? (check all that apply)
COPD
b. In what year were you first diagnosed with COPD?
2. Have you had any of the following studies? (check all that apply)
3. If you know your percent predicted FEV1, enter the value:
b. If you know your alpha-1 antitrypsin type, which is it?
%
a. Do you know the results of your alpha-1 antitrypsin test?
If Yes , answer the following:
3. Does your chest ever sound like it is wheezing or whistling?
a. With a cold
b. Apart from colds
c. Most days
Breathlessness
1. At the present time, are you limited in your activities because of breathing problems?
2. If you are limited, how much are you limited?
1. Have you smoked at least 100 cigarettes (5 packs) in your entire life?
2. If you smoked, how old were you when you started smoking?
years old
3. If you have quit smoking, how old were you when you quit smoking?
years old
4. How many years did you smoke or have you smoked cigarettes?
years
5. On average, how many cigarettes do you/ did you smoke per day?
6. During the last year, have you stopped smoking for at least one day because you wanted to quit smoking?
Currently
In the past
--
Smoking History
3. Do you have to stop for breath after you walk a few minutes on level ground (about 100 yards)?
1. What respiratory illnesses or diseases have you had? (Answer all that apply.)
Respiratory History
2. Have you taken part in a formal pulmonary rehabilitation program?
Age at onset
Age at onset
Age at onset
1. Have you used medications to treat your breathing problems?
If Yes , mark all that apply.
Corticosteroids
Inhaled anticholinergics
Inhaled beta-agonists
Other
Currently
In the past
Aerobid / flunisolide
Azmacort / triamcinolone
Flovent / fluticasone
Prednisone, Medrol / methylprednisolone
Pulmicort Turbohaler / budesonide
Qvar, Vanceril / beclomethasone
Atrovent / ipratopium
Spiriva / tiotropium
Foradil / formoterol
Serevent / salmeterol
Ventolin, Proventil / albuterol
Mucomyst / N-acetyl-cysteine
guaifenesin / expectorant / cough syrup
Theo-Dur, Theolair-24, Uni-Dur, Uniphyl / theophylline
Combination inhalers
Advair / salmeterol and fluticasone
Combivent / albuterol and ipratropium
Singulair / montelukast
Medication
2. Do you use oxygen at home?
Family History
3. Do any of your family members have the following problems?
1. How many siblings did you grow up with?
2. How many children do you have?
Any
Sibling
Any
Child

Father
Mother
Emphysema
Chronic bronchitis
Alpha-1 antitrypsin
deficiency
If Yes , who?
If Yes , who?
If Yes , who?
If Yes , who?
Smoking
If Yes , who?
Yes
No
Uncertain
COPD
Exacerbations
1. Over the last year, how many times have you had breathing problems that required:
a. Antibiotics
None
1
2
3
4+
b. Prednisone
c. Visit to a physician
d. Visit to an emergency room
e. Hospitalization
f. Intensive care unit
1. Gender
2. Age
years
General
Referrals
1. Do you know any smokers who have little or no lung disease who might be willing to participate in this study?