Belenos Asthma Study – Screening Questionnaire

Full Name

Email Address

Phone Number (10-digit US)

Date of Birth

Format: Month/Day/Year (e.g., 01/15/1990)

City and State

Have you been diagnosed with asthma for more than 12 months?

Yes No

Are you currently using an albuterol rescue inhaler and/or a daily controller inhaler?

Yes No

Are you able and willing to complete 16 visits over the next 12 months?

Yes No

Have you smoked any tobacco or nicotine products in the last 6 months?

Yes No

Do you have a significant smoking history?

Yes No

Are you willing to undergo a drug screening?

Yes No

Contact for future studies?

Yes No

What types of studies would you be interested in?

List comma separated keywords