* = required field

Q1-Self *
Q2-First Name *
Q3-Middle *
Q4-Last Name *
Q5-Street Address *
Q6-City *
Q7-State *
Q8-Zip *
Q9-Home Phone
Q10-Cell
Q11-Email
Q12-Age
Q13-Weight
Q14-Smoker
Q15-Packs smoked per day
# of years smoked
Q16-Inhaler
Q17-Medication
Q18-Exacerbations
Q19-Pulmonary
Q20-Conditions
Q21-Treated
Q22-Allergy
Q22b – Allergy Explanation
Q23-Anaphylaxis
Q24-Abuse
Q25-Cancer
Q26-Remission
Q27-HIV
Q28-Child
Q29-Pregnant
Q30-Birth Control
Q31-Enrolled
Q32-Available
Q33- Best Phone
Q34-Permission
Q35- Best Phone 2
Q36- Permission
Q37- Permission
Registration Method
Start Time of Call   at

 

 

 

 

 

 

End Time of Call   at

 

 

 

 

 

 

Phone Number Called
Patient Contacted
Visit Scheduled for   at

 

 

 

 

 

 

Study ID