Thomas Jefferson University Department of Medicine

Department of Medicine - Division of Critical Care

Do you have breathing problems?

Do you experience shortness of breath? persistent cough? Has a doctor ever told you that you may have Asthma, Chronic Bronchitis or Emphysema?

If you have breathing problems, Thomas Jefferson University’s Division of Pulmonary Medicine is currently seeking individuals to participate in ongoing research studies.

Research participants will receive:

Exam by pulmonary specialists
All study-related drugs
Reimbursement for time and travel

To see if you qualify, Please complete the questions below. A coordinator will be in contact with you.

Has a doctor every told you that you have:

	Asbestosis		Asthma
	Bronchitis		COPD
	Emphysema		Pulmonary Fibrosis
	Sarcoidosis

Are you a Smoker?

Yes No

Do You Have a family history of lung Disease?

Yes No

Are you taking any of the following Breathing Medications?

	Accolade		Advair
	Albuterol/Proventil		Atrovent
	Azmacort		Flovent
	Prednisone		Serevent
	Singulair		Vanceril
	Xopenex

Are you taking any other Medications?

Yes No

First Name:

Last Name:

Address:

City:

State:

Postal Code:

Home Phone: (215-555-1212)

Cell Phone: (215-555-1212)

Work Phone: (215-555-1212 extension)

Best Time to Call:

Best Place Call:

Date of Birth: (mm/dd/yyyy)

E-Mail Address:

Yes, I would like to recieve your newsletter.

Thank You for taking the time to fill out our questionnaire.

The Information you have provided will be kept confidential under TJU privacy laws.

Printed from the Thomas Jefferson University Website ( http://www.jefferson.edu/criticalcare/survey.cfm )
Maintained by Bharat Awsare (Bharat.Awsare@jefferson.edu) Copyright © Thomas Jefferson University. All Rights Reserved.
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