Questions Asked on Profile

1. Name, year of birth, sex.

2. Resident state and E-mail address, or other means for others of this list to contact you. 2a. Are you a caregiver? If so, please state your name and your relationship with the person completing the questionnaire.

3. Type of COPD. (Asthma, Chronic Bronchitis, Emphysema)

4. Age when first diagnosed with COPD.

5. At what age did symptoms first appear?

6. What first prompted your visit to Dr.?

7. Were you referred to a pulmonologist.

8. What type of tests were given to diagnose your condition?

9. Who directed the tests, and do you feel you received sufficient information to understand your condition?

10. Were you pre-tested for the effectiveness of any of your medicines?

11. What types of inhalers are you on now? What dosages?

12. Of those you have taken in the past, which were least effective?

13. What types of oral medicines are you now taking and at what dosages?

14. Of those you have taken in the past, which were least effective?

15. Are you using anti-depressants or tranquilizers? What types and dosages?

16. Did you experience any adverse reactions to any of your medications? If so please describe the medicine and the type of reaction.

17. Was any type of re-hab facilities suggested? Any specific types of exercises?

18. Are you using any type of nebulizer? What types of medicines do you use in it.

19. Are you currently using supplemental oxygen? Please describe how often.

20. Are you having problems with any of the following; intolerance to heat or cold, incontinence, sleeplessness, or any other maladies you feel are unusual?

21. Are you currently employed, part-time, full time?

22. Are you on full or partial disability as a result of your illness?

23. Do you have private insurance, Medicare, or belong to an HMO. Do you feel your coverage is sufficient?

24. Have you had, or scheduled to have Lung Volume Reduction surgery or lung transplantation?

25. Are you available for individual questions from others in our group? If so, please state the times and media they should use, if other than that answered in question#2..

26. Please include any personal observations or remarks:

27. Smoker? Yes, Former, or Never

28. Do you currently exercise?

29. What, in your experience, is the most effective antibiotic you have taken for upper respiratory infection?

30. Have you ever been tested for Alpha1 ....(genetic emphysema)?

Emphysema Foundation For Our Right To Survive   2005
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