TRACK Asthma Study – Screening Questionnaire

Who are you completing this questionnaire for?

I am the candidate I am the parent/legal guardian

If the candidate is 18 years or older, provide the candidate's contact information below. If the candidate is under 18 years old, provide the parent/legal guardian's contact information below.

Full Name

The candidate's name if they are 18 or older, otherwise the parent/legal guardian's name.

Email Address

Phone Number

Candidate's Date of Birth

Format: Month/Day/Year (e.g., 01/15/2015). This is the candidate's date of birth.

City and State

Do you consent to being contacted about future research studies?

Yes No

What types of studies would you be interested in?

List comma separated keywords

About the remaining questions

From this point forward, please answer all remaining questions about the candidate.

Has a physician (doctor) ever diagnosed the candidate with asthma?

Yes No

What is the candidate's age?

Under 5 years 5 years or older

Which asthma medication(s) is the candidate currently using? (Select all that apply.)

Albuterol (rescue inhaler) only Albuterol plus another asthma medication Controller medication only (e.g., inhaled corticosteroid) No asthma medication Other

Please list the names of any asthma medications currently being used:

During the past few weeks, has the candidate experienced asthma symptoms on 2 or more days per week?

Yes No

Which of the following asthma symptoms has the candidate experienced? (Select ALL that apply.)

Coughing Wheezing Shortness of breath Chest tightness Activity limitation due to asthma Nighttime awakening because of asthma

Is the candidate able and willing to perform breathing tests (spirometry) and exhaled nitric oxide (FeNO) testing during study visits?

Yes No Not sure

Is the candidate able and willing to attend 2 study visits at 8585 West Forest Home Avenue, Suite 200, Greenfield, WI 53228?

Yes No

Which option BEST describes the candidate's smoking history?

Never smoked Former light smoker — less than 1/2 pack per day for fewer than 20 years About 1/2 pack per day for 20 years or more About 1 or more packs per day for 10 years or more

Has the candidate used any inhaled corticosteroid (ICS) asthma medication within the past 2 weeks, such as Symbicort, Advair, Wixela, Breo, Flovent, Pulmicort, or QVar?

Yes No Not sure

Is the candidate currently diagnosed with any other chronic lung disease or respiratory condition other than asthma, such as COPD, pulmonary fibrosis, bronchiectasis, or another chronic respiratory disease?

Yes No

This study involves breathing tests to help researchers learn more about asthma. It does not involve any new drug or treatment. Do you understand that taking part is completely voluntary, and that you or the candidate can stop at any time without any effect on your regular medical care?

Yes, I understand No, I have questions