Potential Participant Questionnaire

Potential Research Participant Questionnaire

Name:*

Date of Birth:*

Please indicate your preference:

Please contact me by phone

Please contact me via e-mail

Please mail me study information

Phone Number:*

Email Address:*

Address:*

City:*

State:

Zip:*

Please indicate the study that you are interested in (COPD, IPF, Asthma):*

Have you been diagnosed by a Medical Doctor with this condition?

Yes

Are you being treated for this condition?

Yes

Are you inquiring about this study for:

Yourself?

Someone else?

Is there another study that is not listed, for which you are interested in for future studies?

*Required