COPD

Fields marked with an * are required.

Do you consent to the collection and processing of your personal data, including information about your race and ethnicity (as applicable), and your health information, including symptoms, diagnoses, medications, and treatments and our sharing of this information for the purpose of recruitment into clinical research studies, determining your eligibility for studies, and provision of other services you requested? *
You may withdraw your consent at any time by contacting us at info@autocruitment.com. Please note that your revocation will not impact any records or health data already collected, disclosed, or processed based on your consent.

Yes

First Name *

Last Name *

Phone Number *

Date of Birth MM/DD/YYYY *

Zip Code or Postal Code *

Are you Male or Female?

Have you been diagnosed by a doctor with COPD (Chronic Obstructive Pulmonary Disease)? *

Are you currently using a COPD prescribed inhaler every day to treat your COPD? *
Please note: This is referring to a regular daily dose. This does not include inhalers used for flare ups such as albuterol or salbutamol (Ventolin™).

How long have you been using a daily inhaler to treat your COPD? *

Are you currently using a triple-therapy inhaler? This includes Trimbow® pMDI, Trelegy® Ellipta® and Trixeo® Aerosphere®, Breztri™ Aerosphere®, Enerzair® Breezhaler.® *
A triple-therapy inhaler combines three inhaled medications to treat COPD.

Do you smoke cigarettes? *

How many total years have you smoked? *
Please enter total number of years smoked, not including periods where you had quit smoking.

On average, how many cigarettes do you, or did you previously smoke per day? *
There are 20 cigarettes in a pack.

Do you have a history of drug or alcohol abuse within the past 12 months? *

Have you regularly used recreational cannabis or cannabis products (including CBD products) within the past 12 months? *

In the last 12 months, have you taken antibiotics or steroids for your COPD, or been hospitalized due to your COPD? *

Do you have a current diagnosis (diagnosed by a doctor) of any of the following respiratory conditions? *
Please select all that apply.

Asthma

Alpha-1 antitrypsin deficiency

Active tuberculosis

Lung cancer

Lung fibrosis

Sarcoidosis

Interstitial lung disease

Unsure

None of the above

Have you been diagnosed (by a doctor) with any other medical conditions? *
(For example: pulmonary hypertension, hepatic disease, renal disease, hematological disease, neurological disease, endocrinal disease, gastrointestinal disease, pulmonary disease).
Please list here or write 'none'.
Please only include conditions which have been diagnosed by a doctor.

Are you taking any medications for your COPD or other health conditions? *
Please list them below or type ‘none’.

Please, select your height from the dropdown below. *

How much do you weigh in Lbs (pounds)? *

If female, are you currently pregnant or breastfeeding?

Are you currently participating in a clinical trial for an investigational drug or device? *

What is the best day/time to reach you via telephone (we know you are busy)? *

The information you are providing here will be processed in accordance with our Privacy Policy, which describes our data privacy practices, including how we share your information with our Research Partners and use your information to send you details about potential clinical trial opportunities. When you submit this information, you consent to AutoCruitment’s use of your data as described in our Privacy Policy. By providing your phone number and clicking “Submit” below, you consent to receive messages, including SMS/MMS text messages, sent by or on behalf of AutoCruitment, with information about research studies for which you may be eligible. By clicking Submit, you also agree to our SMS Terms. If you have any questions regarding the handling of the information you have provided to AutoCruitment, or if you would like to make any changes or withdraw your consent, please contact us at info@autocruitment.com.