1.

Your Gender

Female

Male

2.

Are you currently on supplementary oxygen?

(Select all that apply.)

Yes, full time.

No

Sometimes

Other:

3.

Your Age

36-45

46-51

52-57

58-63

64-69

70-75

75-80

80 or more

Other:

4.

Are you more than 50 pounds overweight?

Yes

No

5.

Do you use a Cpap or Bipap to Sleep?

Yes

No

Sometimes

Other:

6.

How long have you been taking Spiriva?

1-3 Months

3-6 Months

6-12 Month

More than 1 year

One Year-6 months

Less than 2 years

More than 2 years

Longer

Not Applicable, see remarks

7.

Have you noticed an improvement?

Yes

No

8.

If Yes, when did you first notice an improvement?

Immediately

Between 1 and 5 weeks

Between 5 and 10 weeks

Between 10 and 15 weeks

Between 15 and 20 weeks

After 20 weeks

Did not experience improvement

9.

What Improvements did you notice?

(Select all that apply.)

Able to do more

Could walk further

Less SOB when sitting

Less Panic if SOB

Not much

Easier to exercise

Disappointed

10.

Have you been able to reduce the use of other drugs/inhalers used for breathing improvement?

Yes

No

11.

If you use other inhalers, what are the primary ones that you use with Spiriva?

(Provide up to three responses.)

12.

Have you experienced any side effects?

Yes

No

Other:

13.

What kind of side effects?

14.

Remarks if it did not work for you.

15.

Other Remarks: