First Name:* must provide value
Last Name Today's Date* must provide value
Today M-D-Y Age* must provide value
You MUST be at least 18 years of age to participate in our studies
Have you ever been to the Asthma Research Center before?* must provide value
Has a doctor told you that you have asthma?* must provide value
How long ago?* must provide value
How often do you experience asthma symptoms per week, such as wheezing, shortness of breath, coughing or chest-tightness?* must provide value
Over the past 4 weeks, how often have you experienced asthma symptoms, on average?
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
When is the last time you used your rescue inhaler?
Do you use any medication for your asthma OTHER than your rescue inhalers?* must provide value
Please check all Inhalers (Puffers) that apply:
Number of Puffs Per Day
Number of Puffs per Day
Number of Puffs Per Day
Number of Puffs per Day
Number of Puffs per Day
Number of Puffs per Day
Number of Puffs per Day
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Number of Puffs per Day
Number of Puffs per Day
Number of Puffs per Day
Number of Puffs per Day
Number of Puffs per Day
Number of Puffs per Day
Number of Puffs per Day
Please check all Oral Medications that apply:
Are you taking any shots or injections for your Asthma?
Please check all Shots and Injections that apply:
Please check all other Asthma Medications that apply:
Number of Puffs per Day
Other Asthma Medications
Number of Puffs per Day
Number of Puffs per Day
Number of Puffs per Day
Number of Pills a Day
Number of Pills a Day
Number of Pills a Day
Number of Pills a Day
Number of Puffs per Day
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
When was the last time?* must provide value
Please enter to the best of your ability
If in the past 12 months, how many times?* must provide value
Do you currently smoke cigarettes?* must provide value
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
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?
Do you currently smoke anything else other than cigarettes, such as marijuana, pipes or cigars?* must provide value
How often do you smoke them?
How Often?
Do you have any other medical conditions?* must provide value
Please Describe Here
Do you currently take any other medications? This includes any other prescription medications, over the counter, vitamins, etc.* must provide value
Please List
What gender do you identify with?* must provide value
Are you pregnant or do you plan on becoming pregnant within the next year?* must provide value
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 Do you have a Social Security # (SSN) or a Taxpayer Identification # (TIN)?* must provide value
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 Which University?
Other* must provide value
Please provide us with the best method to contact you:* must provide value
Cell Phone Email Address Home Phone May the Asthma Research Center send you occasional text messages regarding appointment scheduling?
Cell Phone:* must provide value
Numbers only- please do not add dashes
Email Address:* must provide value
Confirm Email Address:* must provide value
Home Phone:* must provide value
Numbers only- please do not add dashes
May we please have another method to contact you? Cell Phone Email Address Home Phone No May the Asthma Research Center send you occasional text messages regarding appointment scheduling? Cell Phone:* must provide value
Numbers only- please do not add dashes
Email Address* must provide value
Confirm Email Address:* must provide value
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 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.)
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