Asthma Research Center :: Participate

Disclaimer: We would like to ask you a series of questions to help us determine whether you might be eligible for studies at the Asthma Research Center. With your permission, we will keep this information until we have determined whether or not you are eligible for our studies. If you are ineligible, we will destroy all your identifiable information. We keep your information confidential. However, not all servers used to send e-mail are secure. You have the option of printing this form and mailing it to us, If you have any questions, you can also give us a call at 617-732-8201. This process should take about 5 minutes to complete.

For general comments or questions please visit our main contact form

Online Form

* indicates a required field

first name: *

last name:

age: *

daytime phone: (xxx-xxx-xxxx)

evening phone: (xxx-xxx-xxxx)

email address: *

confirm email address: *

Where did you hear about us? *

Other :

Has a doctor told you that you have asthma? Yes No

Do you smoke cigarettes, pipes or cigars? * Yes No

If Yes, how many packs per day ?
Less than half pack
Half pack
More than half pack
1 pack
More than 1 pack

If Yes, how long have you smoked? years

Did you ever smoke cigarettes? * Yes No

If Yes, how many packs per day ?
Less than half pack
Half pack
More than half pack
1 pack
More than 1 pack

If you have smoked in the past, how long did you smoke? years

Do you smoke anything else other than cigarettes? Yes No

If Yes, How often do you smoke them?
Daily
Once a week
Once a month
Once a year

How often do you use your rescue medication to relieve your asthma symptoms (example: Albuterol, Ventolin, Proventil, Proair, Atrovent, Combivent etc..) ?

Less than 3 times a week
3-7 times a week
More than 7 times a week
None

Do you use any medication for your asthma other than your rescue medication?
Yes No

If yes, please check all that apply.

Advair 500/50 Advair 250/50 Advair 100/50
Number of puffs/day Other

Advair HFA 45/21 Advair HFA 115/21 Advair HFA 230/21
Number of puffs/day Other

Accolate 10 (Zafirlukast) Accolate 20 (Zafirlukast)
Number of puffs/day Other

Asmanex 220 (mometasone)
Number of puffs/day Other

Azmacort 100 (Triamcinolone)
Number of puffs/day Other

Beclovent 80 (Beclomethasone) Beclovent 40 (Beclomethasone)
Number of puffs/day Other

Flovent 220 (Fluticasone) Flovent 110 Flovent 44 Flovent Diskus 50
Number of puffs/day Other

Foradil Aeroliser 12 (Formoterol)
Number of puffs/day Other

Intal 800 (Cromolyn )
Number of puffs/day Other

Pulmicort 180 (Budesonide) Pulmicort 90 Pulmicort 200
Number of puffs/day Other

Qvar 80 (Beclomethasone) Qvar 40 (Beclomethasone)
Number of puffs/day Other

Serevent Diskus 50 (Salmeterol)
Number of puffs/day Other

Singulair 10 (Montelukast)
Number of puffs/day Other

Symbicort 80/4.5 (Budesonide/Formoterol) Symbicort 160/4.5
Number of puffs/day Other

Theophylline 100 Theophylline 200 Theophylline 300 Theophylline 400
Number of puffs/day Other

Tilade 1.75 (Nedocromil)
Number of puffs/day Other

Other medication
Number of puffs/day Other

Do have any other medical conditions?
Yes No

If yes, please check all that apply.
Lung problems Liver problems Heart problems Kidney problems	Others: 250 char max

Are you on any other medication other than asthma medication?
Yes No

If yes, 250 char max

Screening takes about 1 1/2 - 2 hours. We pay for parking and procedures performed at the visits. If you could, please give us some times that may be convenient for you to come in for screening beginning next week?

(dd/mm/yyyy)

time

(dd/mm/yyyy)

time

(dd/mm/yyyy)

time

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