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Participation Pre-Screen Form

Name:
E-mail Address:
Birthday:	(MM/DD/YYYY)
Address:
City:	State: Zip:
Phone Number (Day):
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Do you have asthma?	Yes No
If yes, when did it start?
Do you have COPD?	Yes No
Have you ever been hospitalized for your asthma?	Yes No
When?
Which medications do you take for your asthma?
Do you have allergies?	Yes No
When did they start?
Which medications do you take for your allergies?
Do you have any other medical conditions?
Any other medications you take regularly?
Do you smoke?	Yes No
Have you ever smoked?	Yes No