Patient Information Form: Asthma

Thank you for your interest in participating in a clinical trial with MDS Pharma Services. Please note that this form is encrypted. Any information collected will be treated as confidential, and will not be shared with third parties without your permission.

Patient Information Submission
Please answer all questions as best you can. Incomplete applications will take longer to process. We will use your information to assess your eligibility for upcoming clinical trials.
Social Security Number/Tax ID Number
 
Name*
As it appears on your government issued ID
 
Email address*
 
Street Address (including number)*
 
City, State, Zip*
Only NE address can participate
 
Cell Phone number*
  ( ) -
Landline
  ( ) -
Language*
 
What is your date of birth?*
 
Current height in inches.*
 
Current weight in pounds.*
 
On average, how many cigarettes do you smoke per day? (Non-smokers, select zero)*
 
FEMALES ONLY: What form of birth control are you using?
Please check the appropriate form of birth control you are currently using. If you check 'None of these', you may not be suitable for this study, but will be contacted in the future.
  Postmenopausal for at least two years
Surgically Sterile (bilateral oopphorectomy, tubal ligation, or hysterectomy)
Intrauterine Devices (IUD)
Diaphragm with spermicide
Hormonal Contraceptives
Condom with spermicide
Lesbian
Withdrawal
Trying to get pregnant
Other
If you answered 'Other', please tell us what form of birth control you use?
 
Do you currently suffer from Asthma?*
  Yes
No
Have you had your condition tested in the last year through a pulmonary function test?*
This is a breathing test which your physician may have performed to test the severity of your asthma.
  Yes
No
We need some detail on what treatment you are currently using.
Asthma treatment falls into a number of categories. Please be sure to note all treatment that you currently use, even if you rarely need to use it.
Inhaled Corticosteroids
Please check the box next to any medications you are currently prescribed.
  Asmabec
Beclazone
Beclometasone
Becodisks
Becotide
Clenil Modulite
QVar
Budesonide
Pulmicort
Cicleslonide
Alvesco
Fluticasone
Flixotide
Mometasone
Asmanex
Fostair
Symbicort
Salmeterol
Serotide
Aerobec Forte
If you checked one of the medications above, how many puffs do you require per week on average?
 
Oral Corticosteroids
Please check the box next to any medications you are currently prescibed.
  Dexamethasone
Cortef
Medrol
Prelone
Prednisone Intensol
Inhaled Long-Acting Beta-2 Agonists
Please check the box next to any medications you are currently prescribed.
  Foradil Aerolizer
Serevent Diskus
If you checked one of the medications above, how many puffs do you require per week on average?
 
Inhaled Short-Acting Beta-2 agonists
Please check the box next to any medications you are currently prescribed.
  Accuneb
Proventil-HFA
ProAir HFA
Beta-2
Isuprel
Xopenex
Xopenex HFA
Maxair Autohaler
Terbutaline Sulfate
If you checked one of the medications above, how many puffs do you require per week on average?
 
Combined Steroids and Long-Acting Beta-2 agonists
Please check the box next to any medications you are currently prescribed.
  Adavair Diskus
Adavair HFA
Symbicort
If you checked one of the medications above, how many puffs do you require per week on average?
 
Other asthma medications
Please check the box next to any other medications you are currently prescribed.
  VoSpire ER
Atrovent
Atrovent HFA
Combivent
Duoneb
Singulair
Accolate
Zyflo CR
Choledyl SA
Elixophyllin
Theo-24
Theocron
Uniphyl
Intal
Tilade
Xolair
If you are using an inhaler or other medication not mentioned above, please give us details here.
Please include as much detail as possible, including the brand name, and the dosage amount, ie 100mcg.
 
Have you visited the ER, been hospitalised, or otherwise treated for a severe asthma attack or exacerbation in the last 6 months?*
  Yes
No
Have you suffered from any respiratory infections recently?*
  Yes
No
Please tick the box next to any conditions you have EVER been diagnosed with.
  Chronic Obstructive Pulmonary Disease (COPD)
Heart Disease
Diabetes (Type I)
Diabetes (Type II)
TB
Listeriosis
Hepatitis B
Hepatitis C
HIV
Cancer
Epilepsy
Heart disease
Drug abuse
Alcohol abuse
Do you currently, or have you ever suffered from any conditions we have not asked you about?
Please give as much detail as possible about any medical history, such as dates and treatments. You don't need to include minor ailments such as the cold or flu.
 
If you were refered by a friend, please give us your friend's name here.
Please ensure you have your friend's permission.
 
Do you possess official photographic ID (Passport, Drivers Licence etc.)*
You will need to bring government issued ID to all appointments at MDS Pharma Services
  Yes
No
Where did you hear about MDS?
Check all that apply
  Facebook
Internet Ad
Newspaper Ad
TV
Radio
Flyer
Word of Mouth
Outreach Event
Only submit your details if you agree to have MDS contact you in relation to future clinical studies.
Confirmation Code:
Enter the code shown in the box before clicking on submit.

Note: Fields marked by an asterisk (*) are required.
Thanks for your interest in clinical research with MDS Pharma Services. We will be in touch soon.