Wendy Moore, Principal Investigator Information About Research
Summary
You are invited to complete a basic questionnaire. The purpose of this questionnaire is to determine if you would be eligible to participate in a clinical research trial at the Airways Clinical Research Center. You are invited to complete the questionnaire because you have breathing issue.
This is an observational study and we will only be asking you to complete one questionnaire. There are risks when you complete anything online. One risk is exposure of Protected Health Information (PHI). We will make every effort to keep your Protected Health Information private. We will store records of your Protected Health Information in a cabinet in a locked office or on a password protected computer.
You may or may not benefit from completing this questionnaire.
You do not have to complete this questionnaire if you do not want to.
Our Research Center will review all completed questionnaires.
There is no cost to you for completing the questionnaire, and there is no compensation to you for completing the questionnaire.
By completing this questionnaire, you give us permission to use your Protected Health Information for this observational study to determine if you would be eligible to participate in a clinical research trial.
For questions about our database the principal investigator or coordinator at 336-713-8550.
The Institutional Review Board (IRB) is a group of people who review the research to protect your rights. If you have a question about your rights as a research participant, or you would like to discuss problems or concerns, have questions or want to offer input, or you want to obtain additional information, you should contact the Chairman of the IRB at (336) 716-4542 or the Research Subject Advocate at (336) 716-8372.
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Who is completing this survey?
* must provide value
Self Caregiver Parent/Guardian Staff member Other
Today's Date
* must provide value
Today M-D-Y
First Name:
* must provide value
You MUST be at least 18 years of age to participate in our studies
Email Address:
* must provide value
Confirm email Address:
* must provide value
Cell Phone:
* must provide value
Numbers only- please do not add dashes
Have you ever been to the Airways Clinical Research Center before?
* must provide value
Yes
No
Unsure
Has a doctor told you that you have asthma?
* must provide value
Yes
No
How long ago?
* must provide value
Less than a year ago
1-5 years ago
5+ years ago
Less than a year ago
1-5 years ago
5+ years ago
In general, how is your asthma control?
Not Controlled at All
Poorly Controlled
Somewhat Controlled
Well Controlled
Completely Controlled
Not Controlled at All
Poorly Controlled
Somewhat Controlled
Well Controlled
Completely Controlled
In general, how often do you use your rescue inhaler or nebulizer (like albuterol or atrovent)?
3 or more times per day
1 or 2 times per day
2 or 3 times per week
Once a week or less
Not at all
3 or more times per day
1 or 2 times per day
2 or 3 times per week
Once a week or less
Not at all
In general, how often does your asthma symptoms wake you from sleep or cause you to wake earlier than usual?
4 or more nights a week
2 to 3 nights a week
Once a week
Once or twice
Not at all
4 or more nights a week
2 to 3 nights a week
Once a week
Once or twice
Not at all
In general, how often do you get short of breath?
More than once a day
Once a day
3 to 6 times a week
Once or twice a week
Not at all
More than once a day
Once a day
3 to 6 times a week
Once or twice a week
Not at all
In general, how much of the time does your asthma stop you from getting as much done as you want at home, school, or work?
All of the time
Most of the time
Some of the time
A little of the time
None of the time
All of the time
Most of the time
Some of the time
A little of the time
None of the time
Do you use any medication for your asthma OTHER than your rescue inhalers?
* must provide value
Yes
No
Unsure
Please check all Inhalers that apply:
Advair 500/50 mcg (or Wixela)
Advair 250/50 mcg
Advair 100/50 mcg
Unsure of Advair dose
Advair 500/50 mcg (or Wixela)
Advair 250/50 mcg
Advair 100/50 mcg
Unsure of Advair dose
Advair HFA 230/21 mcg
Advair HFA 115/21 mcg
Advair HFA 45/21 mcg
Unsure of Advair HFA dose
Advair HFA 230/21 mcg
Advair HFA 115/21 mcg
Advair HFA 45/21 mcg
Unsure of Advair HFA dose
AirDuo Respi Click 232/14 mcg
AirDuo Respi Click 113/14 mcg
AirDuo Respi Click 55/14 mcg
Unsure of AirDuo Respi Click dose
AirDuo Respi Click 232/14 mcg
AirDuo Respi Click 113/14 mcg
AirDuo Respi Click 55/14 mcg
Unsure of AirDuo Respi Click dose
Breo Ellipta 200/25 mcg (fluticasone furoate and vilanterol)
Breo Ellipta 100/25 mcg (fluticasone furoate and vilanterol)
Unsure of Breo Ellipta dose
Breo Ellipta 200/25 mcg (fluticasone furoate and vilanterol)
Breo Ellipta 100/25 mcg (fluticasone furoate and vilanterol)
Unsure of Breo Ellipta dose
Dulera 200/5 mcg
Dulera 100/5 mcg
Unsure of Dulera dose
Dulera 200/5 mcg
Dulera 100/5 mcg
Unsure of Dulera dose
Symbicort 160/4.5 mcg (budesonide/formoterol)
Symbicort 80/4.5 mcg (budesonide/formoterol)
Unsure of Symbicort dose
Symbicort 160/4.5 mcg (budesonide/formoterol)
Symbicort 80/4.5 mcg (budesonide/formoterol)
Unsure of Symbicort dose
ArmonAir RespiClick 232 mpg (fluticasone propionate)
ArmonAir RespiClick 113 mpg (fluticasone propionate)
ArmonAir RespiClick 55 mpg (fluticasone propionate)
Unsure of ArmonAIr RespiClick dose
ArmonAir RespiClick 232 mpg (fluticasone propionate)
ArmonAir RespiClick 113 mpg (fluticasone propionate)
ArmonAir RespiClick 55 mpg (fluticasone propionate)
Unsure of ArmonAIr RespiClick dose
Aerospan HFA 80 mcg (flunisolide HFA)
Unsure of Aerospan dose
Aerospan HFA 80 mcg (flunisolide HFA)
Unsure of Aerospan dose
Alvesco (ciclesonide) 160
Alvesco (ciclesonide) 80
Unsure of Alvesco dose
Alvesco (ciclesonide) 160
Alvesco (ciclesonide) 80
Unsure of Alvesco dose
Arnuity Ellipta (fluticasone furoate) 200 mcg
Arnuity Ellipta (fluticasone furoate) 100 mcg
Unsure of Arnuity Ellipta dose
Arnuity Ellipta (fluticasone furoate) 200 mcg
Arnuity Ellipta (fluticasone furoate) 100 mcg
Unsure of Arnuity Ellipta dose
Asmanex 220 mcg (mometasone)
Asmanex 110 mcg (mometasone)
Unsure of Asmanex dose
Asmanex 220 mcg (mometasone)
Asmanex 110 mcg (mometasone)
Unsure of Asmanex dose
Asmanex twisthaler 220 mcg (mometasone)
Asmanex twisthaler 110 mcg (mometasone)
Unsure of Asmanex twisthaler dose
Asmanex twisthaler 220 mcg (mometasone)
Asmanex twisthaler 110 mcg (mometasone)
Unsure of Asmanex twisthaler dose
Flovent 220 mcg (fluticasone)
Flovent 110 mcg (fluticasone)
Flovent 44 mcg (fluticasone)
Unsure of Flovent dose
Flovent 220 mcg (fluticasone)
Flovent 110 mcg (fluticasone)
Flovent 44 mcg (fluticasone)
Unsure of Flovent dose
Flovent Diskus 500 mcg
Flovent Diskus 250 mcg
Flovent Diskus 100 mcg
Unsure of Flovent Diskus dose
Flovent Diskus 500 mcg
Flovent Diskus 250 mcg
Flovent Diskus 100 mcg
Unsure of Flovent Diskus dose
Pulmicort 180 mcg (budesonide)
Pulmicort 90 mcg (budesonide)
Unsure of Pulmicort dose
Pulmicort 180 mcg (budesonide)
Pulmicort 90 mcg (budesonide)
Unsure of Pulmicort dose
Qvar 80 mcg
Qvar 40 mcg
Unsure of Qvar dose
Qvar 80 mcg
Qvar 40 mcg
Unsure of Qvar dose
Foradil (formoterol) 12 mcg
Foradil (formoterol) 12 mcg
Atrovent 17 mcg
Spiriva (tiotropium) 18 mcg/inhalation
Spiriva (tiotropium) 18 mcg/inhalation
Please check all Oral Medications that apply:
Please check all other Asthma Medications that apply:
Are you taking any shots or injections for your Asthma?
Yes
No
Please check all shots or injections you are currently receiving for your Asthma:
Have you ever taken steroids in a pill form (medrol, deltasone, prednisone, etc) or received it in an injection form (Kenalog, solumedrol, triamcinolone, etc) for your asthma?
* must provide value
Yes
No
Unsure
When was the last time?
* must provide value
Within the last six weeks?
Within the last six months?
Within the past twelve months?
Within the past five years?
More than five years ago?
Unsure
Within the last six weeks?
Within the last six months?
Within the past twelve months?
Within the past five years?
More than five years ago?
Unsure
Please enter to the best of your ability
Do you currently smoke cigarettes?
* must provide value
Yes
No
How many years have you smoked?
* must provide value
How many packs a day do you smoke, on average?
* must provide value
Number of Packs
Did you ever smoke cigarettes?
* must provide value
Yes
No
How many years did you smoke for?
* must provide value
How many packs a day did you smoke, on average?
* must provide value
Number of Packs
View equation When did you quit smoking?
* must provide value
Within the past month?
Within the past 6 months?
Within the past 12 months?
Within the past 5 years?
More than 5 years ago?
Unsure
Within the past month?
Within the past 6 months?
Within the past 12 months?
Within the past 5 years?
More than 5 years ago?
Unsure
Do you currently smoke anything else other than cigarettes, such as marijuana, pipes cigars, vapes, or e-cigarettes?
* must provide value
Yes
No
How often do you smoke them?
Daily
Once a Week
Once a Month
Once a Year
Other Frequency
Daily
Once a Week
Once a Month
Once a Year
Other Frequency
Do you have any other medical conditions?
* must provide value
Yes
No
Do you currently take any other medications? This includes any other prescription medications, over the counter, vitamins, etc.
* must provide value
Yes
No
What gender do you identify with?
* must provide value
Male
Female
Other
What race do you identify with?
Caucasian
Black/African American
Asian
American Indian/Native Alaskan
Native Hawaiian/Other Pacific Islander
More than one race
Other
Caucasian
Black/African American
Asian
American Indian/Native Alaskan
Native Hawaiian/Other Pacific Islander
More than one race
Other
What is your height in inches?
Certain drugs have weight restrictions: What is your weight in pounds?
View equation For the purpose of reimbursement, do you have a Social Security # (SSN) or a Taxpayer Identification # (TIN)?
* must provide value
Yes
No
Where did you hear about us?
* must provide value
At the beginning of the survey, you provided us with your email address and cell phone number. Can you please provide us with the best method to contact you?
* must provide value
Cell Phone
Email Address
May the Airways Clinical Research Center send you occasional text messages regarding appointment scheduling?
Yes
No
May the Airways Clinical Research Center at Wake Forest School of Medicine leave you a voice mail at the above number(s)? (Our voicemail will say that you have a call from the research center at Wake Airways Clinical Research Center, but will not mention asthma.)
Yes
No
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