EFFORTS Members
Questionnaire

Please note, all answers are on a voluntary basis only. This information will be available to all new members, plus those members who have shown a desire to participate. This is intended as an information exchange forum to help each of us in seeking some assistance in coping with our disease. This puts us on a one to one basis with those in our own age groups, severity of disease, as well as medicine effectiveness. Disclaimer: This information may be accessed by the public.

IF YOU ARE A CAREGIVER, AND WISH TO PARTICIPATE IN THIS FORUM, PLEASE SUPPLY US WITH THE PERTINENT INFORMATION, INCLUDING YOUR OWN BACKGROUND AND EXPERTISE.

The questions are numerical. Please respond by question number only, no need to repeat the question itself. i. e.,
1. First name Last, 1933, male
2. Missouri Chasd@worldnet.att.net 
2a. None

PLEASE USE "LAY" TERMS WHEN POSSIBLE, FOR THOSE WHO MAY NOT UNDERSTAND OTHERWISE.

For those wishing to complete this questionnaire for the benefit of others but need help doing so, please contact Joan Esposito . vze4z944@VERIZON.NET 
 

 

1. Name, year of birth, sex.


2. Resident state and/or email address
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)?

For comments, please send message to  vze4z944@VERIZON.NET .
Copyright © 2003 [EFFORTS]. All rights reserved.
Revised: 08/07/07