1.

Your Age:

2.

Your Gender

(Select all that apply.)

Female

Male

3.

Your Occupation (Previous if now disabled or retired)

4.

Your Highest Education

(Select all that apply.)

High school

Some college

Undergraduate degree

Some graduate school

Graduate degree

Other:

5.

How long (in years) has it been since your first diagnosis? If less than 10, show a 0 before the letter i.e. .05

6.

If you were a smoker, How soon did you quit smoking after diagnosis?

7.

Are you still smoking?

Yes

No

8.

If you smoked, how many cigarettes per day?

9.

Did your doctor recommend Pulmonary Rehab?

Yes

No

10.

Have you been through Pulmonary Rehab?

Yes

No

11.

Was Pulmonary Rehab available to you? (If no, explain in remarks.)

Yes

No

Other:

12.

How was your diagnosis termed?

Asthma

Chronic Bronchitis

Emphysema

COPD

Other

13.

Have you ever been tested for Alpha One?

Yes

No

14.

Are you on Oxygen?

No

Yes, full time

Nighttime Only

Exercise Only

15.

If so, was your need for oxygen determined by:

(Select all that apply.)

Your doctor?

Actual Walking Test?

Pulmonary Function Tests?

Other

16.

What have you been told about increasing or reducing the rate of flow by your doctor?

17.

What regular settings (LPM) are you on now with your oxygen?

18.

Do you understand your instructions for handling your oxygen? Turning up and down, off, etc..?

19.

Your primary insurance coverage is:

(Select all that apply.)

Medicare

Medicaid

Private

Employer

None

20.

Do you consider yourself homebound?

Yes

No

21.

Remarks