Complete this survey to see if you pre-qualify

See if you pre-qualify

Thank you for considering participating in our clinical trial. This survey helps expedite your enrollment process and ensures you are matched to the best clinical trial for your unique health condition.

Please allow 10 minutes to complete this survey.
**A team member will reach out to confirm the information provided.**

**To qualify you must be able to speak, read, and write in English without assistance.**

Your responses are being used strictly to determine eligibility.
We never share your personal information.
What is your full name?*

First NameLast Name
What is your email address?*
example@example.com
How can we reach you by phone?*
Please enter a valid phone number.
When is your birthday?*

MonthDayYear
Date
What was your gender assigned at birth?*

FemaleMalePrefer not to sayPrefer to self-describe
Please describe your gender assigned at birth.
Today

MonthDayYear
Date
Age
Location
I agree to be contacted by phone or sms (text messaging) about this study or any other studies of interest I select.
Privacy Policy

Are you able to speak, read, and write in English without assistance?*

YesNo
Would you still like to submit your information in case you become eligible for a future study?*

YesNo
Please confirm your understanding that all steps of the clinical trial recruitment process will be conducted in English.*

I acknowledge that all steps in the clinical trial recruitment process will be conducted in English.
Please confirm your understanding that some steps of the clinical trial recruitment process require in-person visits to one of our clinical trial sites.*

I acknowledge that some steps of the clinical trial recruitment process require in person visits.

What is your weight and height.*
Are you currently pregnant or breastfeeding?*

YesNo
What is your smoking history?*

Current smokerPrevious smokerI have never smoked
Do you have a history of alcohol dependency?*

YesNo
Are you currently enrolled in any other studies?*

YesNo

Are you willing to take study medications?*

YesNo
Are you willing to complete tests and exams related to this condition study?*

YesNo
Do you have a study partner available to attend appointments (If required by study)?*

YesNo
Are you willing and able to provide medical records/labs and a complete medical history upon request?*

YesNo

Unfortunately, the criteria for this study have not been met.

We appreciate your valuable contribution and would like to stay in touch with you.
Would you like to be contacted in the future about other studies that interest you?*

YesNo

Thank you for filling out the form.

Your information will not be kept and you will not be contacted.

COPD