Questions
1.
What is your date of birth? (Must be between 40 and 74 years old to participate.)
1
2
3
4
5
6
7
8
9
10
11
12
/
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
(Month/Day/Year)
2.
What is your gender (sex)?
Female
Male - skip to question 6
3.
Are you currently pregnant, or planning to become pregnant in the next 6 months?
Yes
No
4.
Can you become pregnant?
Yes
No
5.
If no, why not?
Post-menopausal
Surgically sterile (tubal ligation or hysterectomy)
Willing to use birth control for the duration of study
None of the above
6.
Are you currently in another investigational research study?
Yes
No
7.
Have you been told you have emphysema by a healthcare professional?
Yes
No
8.
Do you have a Pulmonary doctor (not your regular M.D.) taking care of you?
Yes
No
9.
What type of emphysema have you been told you have?
Upper lobe
Lower lobe
All over
Unsure
10.
When was your last CT scan?
Less than 1 year ago
Over 1 year ago
Never
Unsure
11.
Have you had pulmonary (lung) function testing (PFTs) in the last 12 months?
Yes
No
Unsure
12.
Are you currently on a lung transplantation list?
Yes
No
13.
Have you been told that you are a candidate for Lung Volume Reduction Surgery?
Yes
No
Unsure
14.
Have you ever had Lung Volume Reduction Surgery?
Yes
No
15.
Have you smoked in the last 4 months?
Yes
No
16.
Are you willing not to smoke for the duration of the study?
Yes
No
17.
Which of the following situations best describe you? (pick only one)
I only get short of breath with moderate to strenuous exercise.
I get short of breath when walking at a faster than normal pace on level ground or up a slight hill.
I get short of breath after walking for a few minutes, even if I walk at my own pace on
level ground.
I get short of breath or have to stop to catch my breath after walking just a short distance.
I am too breathless to leave my home.
18.
Are you currently using oxygen?
Yes
No - Skip to question 20
19.
When do you use oxygen?
During sleep only
During sleep and during exercise
All the time
20.
Do you have any of these?
Active asthma
Chronic bronchitis
Bronchiectasis (an enlargement of the airways due to repeated lung problems, such
as pneumonia)
Uncontrolled high blood pressure
Pulmonary hypertension
Active cancer
None
Unsure
21.
As part of this study you may need to have medical testing. This testing may require you to visit the medical center up to 4 times, in order to complete these tests. Are you able to get transporation to the medical center and participate in these health assessment visits?
Yes
No
22.
Have you ever "passed out" while you were exercising?
Yes
No
23.
As part of this research study, you will stay in the hospital for an overnight stay. Would you be willing to stay overnight in the hospital?
Yes
No
24.
Can a message be left on your phone?
Yes
No
Contact Information
First Name:
Middle Initial:
Last Name:
E-Mail Address:
Confirm E-Mail Address:
Phone:
Address 1:
Address 2:
City:
State:
Zip:
Country:
Comments:
