Today's Date* must provide value
Today M-D-Y First Name:* must provide value
Last Name Age* must provide value
You MUST be at least 18 years of age to participate in our studies
Email Address:* must provide value
Confirm email Address:* must provide value
Cell Phone:* must provide value
Numbers only- please do not add dashes
Have you ever been to the Asthma Research Center before?* must provide value
Yes
No
Unsure
Has a doctor told you that you have asthma?* must provide value
Yes
No
How long ago?* must provide value
Less than a year ago
1-5 years ago
5+ years ago
In general, how is your asthma control? Not Controlled at All
Poorly Controlled
Somewhat Controlled
Well Controlled
Completely Controlled
In general, how often do you use your rescue inhaler or nebulizer (like albuterol or atrovent)? 3 or more times per day
1 or 2 times per day
2 or 3 times per week
Once a week or less
Not at all
In general, how often does your asthma symptoms wake you from sleep or cause you to wake earlier than usual? 4 or more nights a week
2 to 3 nights a week
Once a week
Once or twice
Not at all
In general, how often do you get short of breath? More than once a day
Once a day
3 to 6 times a week
Once or twice a week
Not at all
In general, how much of the time does your asthma stop you from getting as much done as you want at home, school, or work? All of the time
Most of the time
Some of the time
A little of the time
None of the time
How often do you experience asthma symptoms per week, such as wheezing, shortness of breath, coughing or chest-tightness?* must provide value
Not always every week
Less than 2 times a week
2-3 times a week
4-7 times a week
More than 7 times a week
Over the past 4 weeks, how often have you experienced asthma symptoms, on average? Not always every week
Less than 2 times a week
At least two times a week
On average, how many times a week do you use your rescue inhaler? (Rescue inhalers include Proair, Albuterol, Ventolin, Maxair and Proventil) Do not include times you used your rescue inhaler if you take it prior to exercising.* must provide value
Not always every week
Less than 2 times a week
2-7 times a week
More than 7 times a week
When is the last time you used your rescue inhaler? Within the past 2 weeks
Within the past 4 weeks
More than 1 month ago
Do you use any medication for your asthma OTHER than your rescue inhalers?* must provide value
Yes
No
Unsure
Please check all Inhalers (Puffers) that apply:
Advair 500/50 mcg
Advair 250/50 mcg
Advair 100/50 mcg
Unsure of Advair dose
Number of Puffs Per Day 1 Puff Once a Day
2 Puffs Once a Day
1 Puff Twice a Day
2 Puffs Twice a Day
More than 2 Puffs Once a day
More than 2 Puffs More than Twice a Day
As Needed
Other
Advair HFA 230/21 mcg
Advair HFA 115/21 mcg
Advair HFA 45/21 mcg
Unsure of Advair HFA dose
Number of Puffs per Day 1 Puff Once a Day
2 Puffs Once a Day
1 Puff Twice a Day
2 Puffs Twice a Day
More than 2 Puffs Once a day
More than 2 Puffs More than Twice a Day
As Needed
Other
AirDuo Respi Click 232/14 mcg
AirDuo Respi Click 113/14 mcg
AirDuo Respi Click 55/14 mcg
Unsure of AirDuo Respi Click dose
Number of Puffs Per Day 1 Puff Once a Day
2 Puffs Once a Day
1 Puff Twice a Day
2 Puffs Twice a Day
More than 2 Puffs Once a day
More than 2 Puffs More than Twice a Day
As Needed
Other
Breo Ellipta 200/25 mcg (fluticasone furoate and vilanterol)
Breo Ellipta 100/25 mcg (fluticasone furoate and vilanterol)
Unsure of Breo Ellipta dose
Number of Puffs per Day 1 Puff Once a Day
2 Puffs Once a Day
1 Puff Twice a Day
2 Puffs Twice a Day
More than 2 Puffs Once a day
More than 2 Puffs More than Twice a Day
As Needed
Other
Dulera 200/5 mcg
Dulera 100/5 mcg
Unsure of Dulera dose
Number of Puffs per Day 1 Puff Once a Day
2 Puffs Once a Day
1 Puff Twice a Day
2 Puffs Twice a Day
More than 2 Puffs Once a day
More than 2 Puffs More than Twice a Day
As Needed
Other
Symbicort 160/4.5 mcg (Budesonide/Formoterol)
Symbicort 80/4.5 mcg (Budesonide/Formoterol)
Unsure of Symbicort dose
Number of Puffs per Day 1 Puff Once a Day
2 Puffs Once a Day
1 Puff Twice a Day
2 Puffs Twice a Day
More than 2 Puffs Once a day
More than 2 Puffs More than Twice a Day
As Needed
Other
Aerospan HFA 80 mcg (flunisolide HFA)
Unsure of Aerospan dose
Number of Puffs per Day 1 Puff Once a Day
2 Puffs Once a Day
1 Puff Twice a Day
2 Puffs Twice a Day
More than 2 Puffs Once a day
More than 2 Puffs More than Twice a Day
As Needed
Other
Alvesco (Ciclesonide) 160
Alvesco (Ciclesonide) 80
Unsure of Alvesco dose
Number of Puffs per Day 1 Puff Once a Day
2 Puffs Once a Day
1 Puff Twice a Day
2 Puffs Twice a Day
More than 2 Puffs Once a day
More than 2 Puffs More than Twice a Day
As Needed
Other
Arnuity Ellipta ( Fluticasone Furoate) 200 mcg
Arnuity Ellipta ( Fluticasone Furoate) 100 mcg
Unsure of Arnuity Ellipta dose
Number of Puffs per Day 1 Puff Once a Day
2 Puffs Once a Day
1 Puff Twice a Day
2 Puffs Twice a Day
More than 2 Puffs Once a day
More than 2 Puffs More than Twice a Day
As Needed
Other
Asmanex 220 mcg (mometasone)
Asmanex 110 mcg (mometasone)
Unsure of Asmanex dose
Number of Puffs per Day 1 Puff Once a Day
2 Puffs Once a Day
1 Puff Twice a Day
2 Puffs Twice a Day
More than 2 Puffs Once a day
More than 2 Puffs More than Twice a Day
As Needed
Other
Asmanex twisthaler 220 mcg (mometasone)
Asmanex twisthaler 110 mcg (mometasone)
Unsure of Asmanex twisthaler dose
Number of Puffs per Day 1 Puff Once a Day
2 Puffs Once a Day
1 Puff Twice a Day
2 Puffs Twice a Day
More than 2 Puffs Once a day
More than 2 Puffs More than Twice a Day
As Needed
Other
Flovent 220 mcg (Fluticasone)
Flovent 110 mcg (Fluticasone)
Flovent 44 mcg (Fluticasone)
Unsure of Flovent dose
Number of Puffs per Day 1 Puff Once a Day
2 Puffs Once a Day
1 Puff Twice a Day
2 Puffs Twice a Day
More than 2 Puffs Once a day
More than 2 Puffs More than Twice a Day
As Needed
Other
Flovent Diskus 500 mcg
Flovent Diskus 250 mcg
Flovent Diskus 100 mcg
Unsure of Flovent Diskus dose
Number of Puffs per Day 1 Puff Once a Day
2 Puffs Once a Day
1 Puff Twice a Day
2 Puffs Twice a Day
More than 2 Puffs Once a day
More than 2 Puffs More than Twice a Day
As Needed
Other
Pulmicort 180 mcg (Budesonide)
Pulmicort 90 mcg (Budesonide)
Unsure of Pulmicort dose
Number of Puffs per Day 1 Puff Once a Day
2 Puffs Once a Day
1 Puff Twice a Day
2 Puffs Twice a Day
More than 2 Puffs Once a day
More than 2 Puffs More than Twice a Day
As Needed
Other
Qvar 80 mcg
Qvar 40 mcg
Unsure of Qvar dose
Number of Puffs per Day 1 Puff Once a Day
2 Puffs Once a Day
1 Puff Twice a Day
2 Puffs Twice a Day
More than 2 Puffs Once a day
More than 2 Puffs More than Twice a Day
As Needed
Other
Foradil (Formoterol) 12 mcg
Number of Puffs per Day 1 Puff Once a Day
2 Puffs Once a Day
1 Puff Twice a Day
2 Puffs Twice a Day
More than 2 Puffs Once a day
More than 2 Puffs More than Twice a Day
As Needed
Other
Serevent Diskus 50 mcg (Salmeterol)
Number of Puffs per Day 1 Puff Once a Day
2 Puffs Once a Day
1 Puff Twice a Day
2 Puffs Twice a Day
More than 2 Puffs Once a day
More than 2 Puffs More than Twice a Day
As Needed
Other
Atrovent 17 mcg
Number of Puffs per Day 1 Puff Once a Day
2 Puffs Once a Day
1 Puff Twice a Day
2 Puffs Twice a Day
More than 2 Puffs Once a day
More than 2 Puffs More than Twice a Day
As Needed
Other
Spiriva (Tiotropium) 18 mcg/inhalation
Number of Puffs per Day 1 Puff Once a Day
2 Puffs Once a Day
1 Puff Twice a Day
2 Puffs Twice a Day
More than 2 Puffs Once a day
More than 2 Puffs More than Twice a Day
As Needed
Other
Azmacort 75 mcg (Triamcinolone)
Number of Puffs per Day 1 Puff Once a Day
2 Puffs Once a Day
1 Puff Twice a Day
2 Puffs Twice a Day
More than 2 Puffs Once a day
More than 2 Puffs More than Twice a Day
As Needed
Other
Please check all Oral Medications that apply: Singulair ( Montelukast )
Theophylline
Zyflo ( Zileuton )
Accolate ( Zafirlukast )
Are you taking any shots or injections for your Asthma? Yes
No
Please check all Shots and Injections that apply: Xolair ( Omalizumab )
Nucala ( Mepolizumab )
Cinquair ( Reslizumab )
Please check all other Asthma Medications that apply: Arcapta Neohaler ( Indacaterol )
Striverdi Respimat ( Olodaterol )
Incruse Ellipta ( Umeclidinium )
Tudorza Pressair ( Aclinidium Bromide )
Anoro Ellipta ( Umeclidinium and Vilanterol )
Stiolto Respimat ( Tiotropium Bromide and Olodaterol )
Number of Puffs per Day 1 Puff Once a Day
2 Puffs Once a Day
1 Puff Twice a Day
2 Puffs Twice a Day
More than 2 Puffs Once a day
More than 2 Puffs More than Twice a Day
As Needed
Other
Other Asthma Medications
Spiriva Respimat (Tiotropium) 5 mcg
Spiriva Respimat (Tiotropium) 2.5 mcg
Unsure of Spriva Respimat dose
Number of Puffs per Day 1 Puff Once a Day
2 Puffs Once a Day
1 Puff Twice a Day
2 Puffs Twice a Day
More than 2 Puffs Once a day
More than 2 Puffs More than Twice a Day
As Needed
Other
Beclovent 84 mcg
Beclovent 42 mcg
Unsure of Beclovent dose
Number of Puffs per Day 1 Puff Once a Day
2 Puffs Once a Day
1 Puff Twice a Day
2 Puffs Twice a Day
More than 2 Puffs Once a day
More than 2 Puffs More than Twice a Day
As Needed
Other
Combivent 120/21
Number of Puffs per Day 1 Puff Once a Day
2 Puffs Once a Day
1 Puff Twice a Day
2 Puffs Twice a Day
More than 2 Puffs Once a day
More than 2 Puffs More than Twice a Day
As Needed
Other
Singulair 10 mg (Montelukast)
Number of Pills a Day
1
2
3+
Theophylline 450 mg
Theophylline 400 mg
Theophylline 300 mg
Theophylline 200 mg
Theophylline 100 mg
Theophylline but unsure of dose
Number of Pills a Day 1
2
3+
Zyflo (Zileuton) 1200 mcg
Zyflo (Zileuton) 600 mcg
Number of Pills a Day 1
2
3+
Xolair Injections
Nucala Injection (Mepolizumab)
Accolate 10 mg (Zafirlukast)
Accolate 20 mg (Zafirlukast)
Number of Pills a Day
1
2
3+
Xopenex (Levalbuterol) 90 mcg
Number of Puffs per Day 1 Puff Once a Day
2 Puffs Once a Day
1 Puff Twice a Day
2 Puffs Twice a Day
More than 2 Puffs Once a day
More than 2 Puffs More than Twice a Day
As Needed
Other
Have you ever taken steroids in a pill form (medrol, deltasone, prednisone, etc) or received it in an injection form (Kenalog, solumedrol, triamcinolone, etc) for your asthma? * must provide value
Yes No Unsure When was the last time?* must provide value
Within the last six weeks?
Within the last six months?
Within the past twelve months?
Within the past five years?
More than five years ago?
Unsure
Please enter to the best of your ability
If in the past 12 months, how many times?* must provide value
0
1
2
3
4+
Unsure
Do you currently smoke cigarettes?* must provide value
Yes No How many years have you smoked?* must provide value
How many packs a day do you smoke, on average? * must provide value
Number of Packs
Did you ever smoke cigarettes?* must provide value
Yes No How many years did you smoke for?* must provide value
How many packs a day did you smoke, on average? * must provide value
Number of Packs
Smoking History View equation
When did you quit smoking?
Within the past month?
Within the past 6 months?
Within the past 12 months?
Within the past 5 years?
More than 5 years ago?
Unsure
Do you currently smoke anything else other than cigarettes, such as marijuana, pipes or cigars?* must provide value
Yes No How often do you smoke them?
Daily
Once a Week
Once a Month
Once a Year
Other Frequency
How Often?
Do you have any other medical conditions?* must provide value
Yes
No
Please Describe Here
Do you currently take any other medications? This includes any other prescription medications, over the counter, vitamins, etc.* must provide value
Yes
No
Please List
What gender do you identify with?* must provide value
Male Female Other Are you pregnant or do you plan on becoming pregnant within the next year?* must provide value
Yes No What race do you identify with? Caucasian Black/African American Asian American Indian/Native Alaskan Native Hawaiian/Other Pacific Islander More than one race Other
What is your Height in Inches? Certain drugs have weight restrictions: What is your weight in pounds? BMI View equation
Do you have a Social Security # (SSN) or a Taxpayer Identification # (TIN)?* must provide value
Yes
No
Where did you hear about us?* must provide value
Birthday Postcard from the Asthma Research Center Boston Herald Newspaper Bus Advertisement Clinicaltrials.partners.org Craigslist Facebook Family/Friend Referral Flyer Outside The Hospital Flyer Within The Hospital Google Ad Instagram Letter From The Asthma Research Center Letter From Your Own Physician Letter/Email From RSVP For Health MD Referral per Patient Agreement Metro Website Metro Newspaper Partners Employee Email Postcard RPDR Letter Search Engine Result Twitter University Job Posting Other Birthday Email from Asthma Research Center Email from Asthma Research Center
Which University?
Other* must provide value
At the beginning of the survey, you provided us with your email address and cell phone number. Can you please provide us with the best method to contact you?* must provide value
Cell Phone Email Address Home Phone
Home Phone:* must provide value
Numbers only- please do not add dashes
May the Asthma Research Center send you occasional text messages regarding appointment scheduling? Yes
No
May the Asthma Research Center leave you a voice mail at the above number(s)? (Our voicemail will say that you have a call from the research center at Brigham and Women's Hospital, but will not mention asthma.)
Yes No May the Asthma Research Center send you occasional text messages regarding appointment scheduling? Yes No Cell Phone:* must provide value
Numbers only- please do not add dashes
Email Address:* must provide value
Confirm Email Address:* must provide value
In case we have to communicate with you via email, the Partners standard is to send email securely. This requires you to initially set up and activate an account with a password. You can then use the password to access secure emails sent to you from Partners HealthCare. If you prefer, we can send you "unencrypted" email that is not secure and could result in the unauthorized use or disclosure of your information. If you want to receive communications by unencrypted email despite these risks, Partners HealthCare will not be held responsible. Your preference to receive unencrypted email will apply to emails sent from this research group/study only.* must provide value
I prefer to receive email securely (requires you to initially set up and activate an account with password.) (You will need to login with your password each time you want to receive or send an email.)
I prefer unencrypted email
May we please have another method to contact you? Cell Phone Email Address Home Phone No
Cell Phone:* must provide value
Numbers only- please do not add dashes
Email Address* must provide value
Confirm Email Address:* must provide value
In case we have to communicate with you via email, the Partners standard is to send email securely. This requires you to initially set up and activate an account with a password. You can then use the password to access secure emails sent to you from Partners HealthCare. If you prefer, we can send you "unencrypted" email that is not secure and could result in the unauthorized use or disclosure of your information. If you want to receive communications by unencrypted email despite these risks, Partners HealthCare will not be held responsible. Your preference to receive unencrypted email will apply to emails sent from this research group/study only.* must provide value
I prefer to receive email securely (requires you to initially set up and activate an account with password.) (You will need to login with your password each time you want to receive or send an email.)
I prefer unencrypted email
Home Phone:* must provide value
Numbers only- please do not add dashes
If you have not done so already, please provide your e-mail address: Confirm Email Address In case we have to communicate with you via email, the Partners standard is to send email securely. This requires you to initially set up and activate an account with a password. You can then use the password to access secure emails sent to you from Partners HealthCare. If you prefer, we can send you "unencrypted" email that is not secure and could result in the unauthorized use or disclosure of your information. If you want to receive communications by unencrypted email despite these risks, Partners HealthCare will not be held responsible. Your preference to receive unencrypted email will apply to emails sent from this research group/study only.* must provide value
I prefer to receive email securely (requires you to initially set up and activate an account with password.) (You will need to login with your password each time you want to receive or send an email.)
I prefer unencrypted email
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