COPD & Heart Disease Research Study – Screening Questionnaire

What is your full name?

What is your email address?

What is your phone number?

What is your date of birth?

Format: Month/Day/Year (e.g., 06/15/1962).

What city and state do you live in?

How your information is protected

Your information is kept confidential and is protected by a federal Certificate of Confidentiality, which means it cannot be shared with anyone outside the research team without your permission — including law enforcement — except in very limited circumstances required by law.

Are you willing to be contacted about future research studies?

Yes No

What types of studies would you be interested in?

List comma separated keywords

Are you able to read and understand English well enough to answer questions and take part in a research study?

Yes No

Are you a current or former cigarette smoker?

Yes, I currently smoke cigarettes Yes, I used to smoke but have stopped No, I have never smoked cigarettes

About how many years did you smoke, or how many years have you been smoking?

On average, about how many packs of cigarettes did you smoke per day? One pack equals 20 cigarettes.

For example: half a pack = 0.5, one pack = 1, two packs = 2.

Have you ever been told by a doctor that you have COPD, emphysema, or chronic bronchitis?

Yes No Unsure

Do you currently experience any of the following? Select all that apply.

Ongoing cough Cough with mucus or phlegm Shortness of breath Wheezing Trouble exercising or doing everyday activities Frequent chest infections None of the above

Are you willing to come to a study clinic in Wisconsin for visits over the course of the study? The study may include up to approximately 12 visits over up to approximately 3 years.

Yes No

Do you have a regular doctor or primary care provider? If yes, are you willing to let the study team contact that doctor?

Yes, I have a doctor and am willing to let the study team contact them Yes, I have a doctor but prefer the study team not contact them No, I do not have a regular doctor

Have you ever had a heart attack (sometimes called a myocardial infarction)?

Yes No Unsure

If you have had a heart attack — did it happen within the past 8 weeks?

Yes, within the past 8 weeks No, it was more than 8 weeks ago Not applicable — I have not had a heart attack

Have you ever had coronary artery bypass graft surgery? This is sometimes called open-heart surgery or CABG.

Yes No Unsure

Have you ever had a coronary stent placed in a heart artery?

Yes No Unsure

Have you ever been told by a doctor that you have significant blockage in two or more of your heart arteries — for example, 50% or more blockage?

Yes No Unsure

Have you had unstable chest pain (sometimes called unstable angina) or a serious irregular heartbeat within the past 8 weeks?

Yes No Unsure

Have you had a COPD flare-up or pneumonia within the past 8 weeks?

Yes No Unsure

Have you ever been told by a doctor that you have asthma?

Yes No Unsure

If you have been told you have asthma — were you diagnosed with or treated for asthma within the past 5 years?

Yes, within the past 5 years No, it was more than 5 years ago or I was never treated for it Not applicable — I have not been told I have asthma

Have you ever had a heart or lung transplant, or are you currently on a waiting list for a transplant?

Yes No

Do you currently use a mechanical pump to help your heart work — sometimes called a left ventricular assist device or LVAD?

Yes No

Have you ever been diagnosed with lung cancer, or have you received treatment for lung cancer within the past 5 years?

Yes No Unsure

Have you used any inhaled corticosteroid medication during the past 12 months? These are inhalers or breathing medicines that may contain ingredients such as budesonide, fluticasone, beclomethasone, or mometasone. Common brand names include Pulmicort, Flovent, QVAR, Asmanex, Symbicort, Advair, Breo, and Trelegy, among others.

Yes No Unsure

Please list all inhalers or breathing medicines you currently use or have used during the past 12 months. Include the name of the inhaler if you know it.

Are you currently taking part in another clinical research study, or have you taken part in one within the past 30 days?

Yes No

This research study compares two study inhalers for COPD — no inactive inhaler or placebo is used. Participants are randomly assigned to one of the two study inhalers. Do you understand this and are you willing to be randomly assigned to either study inhaler?

Yes, I understand and am willing No, I am not willing

Taking part in this study is completely your choice. You can ask questions and take time to decide before agreeing to anything. Answering these questions does not sign you up or commit you to participating. Do you understand this?

Yes, I understand No, I have questions first