1Tell us about yourself2Height and Weight3Your Asthma4Your lifestyle & statusName* First name Last name Gender* Male FemaleDate of Birth* DD dash MM dash YYYY Your email address* Best contact number*Maximum of 11 digits. Avoid spaces. (e.g. 07912345678 or 02077561414)Height (in cm)*Weight (in kg)*HiddenBMIHave you been diagnosed with asthma more than 6 months ago?* Yes NoAre you prescribed an inhaler to treat your asthma?* Yes NoWhich inhaler(s) are you prescribed?You can select more than one option Reliever Preventer/Controller inhaler Combination inhalerRelieverWhich Reliever do you use?Select only onePlease selectAiromir - usually blue in colour (Salbutamol)Ventolin - usually blue in colour (Salbutamol)Asmalal - usually blue in colour (Salbutamol)Easi-breathe - usually blue in colour (Salbutamol)Easyhaler - usually blue in colour (Salbutamol)Pulvinal - usually blue in colour (Salbutamol)Salamol - usually blue in colour (Salbutamol)Bricanyl (Terbutaline)Atrovent (Ipratropium)Other (not listed)I do not know the nameHow frequently do you use your chosen Reliever?Select only one When required Once a day Twice a day (or more) Weekly Fortnightly MonthlyPreventer/Controller inhalerWhich Preventer/Controller inhaler do you use?Select only onePlease selectAlvesco 80 inhaler (Ciclesonide )Alvesco 160 inhaler (Ciclesonide )Arnuity Ellipta 100mcg (Fluticasone furate)Arnuity Ellipta 200mcg (Fluticasone furate)Asmanex Mometasone 100 mcg inhaler (Mometasone furoate)Asmanex Mometasone 200 mcg inhaler (Mometasone furoate)Asmanex Twisthaler 200mcg (Mometasone furoate)Asmanex Twisthaler 400mcg (Mometasone furoate)Budelin Novolizer 200mcg (Budesonide)Clenil 50 inhaler (Beclometasone dipropionate)Clenil 100 inhaler (Beclometasone dipropionate)Clenil 200 inhaler (Beclometasone dipropionate)Clenil 250 inhaler (Beclometasone dipropionate)Easyhaler Beclometasone 200mcg (Beclometasone dipropionate)Easyhaler budesonide 100mcg (Budesonide)Easyhaler budesonide 200mcg (Budesonide)Easyhaler budesonide 400mcg (Budesonide)Flixotide Accuhaler 50 (Fluticasone propionate)Flixotide Accuhaler 100 (Fluticasone propionate)Flixotide Accuhaler 250 (Fluticasone propionate)Flixotide Accuhaler 500 (Fluticasone propionate)Flixotide inhaler 50 (Fluticasone propionate)Flixotide inhaler 125 (Fluticasone propionate)Flixotide inhaler 250 (Fluticasone propionate)Kelhale 50 inhaler (Beclometasone dipropionate)Kelhale 100 (Beclometasone dipropionate))Pulmicort 100 turbohaler (Budesonide)Pulmicort 200 turbohaler (Budesonide)Pulmicort 400 turbohaler (Budesonide)Qvar 50 Autohaler (Beclometasone dipropionate)Qvar 50 Easi-Breathe (Beclometasone dipropionate)Qvar Inhaler 50 (Beclometasone dipropionate)Soprobec 50 inhaler (Beclometasone dipropionate)Soprobec 100 inhaler (Beclometasone dipropionate)Soprobec 200 inhaler (Beclometasone dipropionate)Soprobec 250 inhaler (Beclometasone dipropionate)Other (not listed)How frequently do you use your Preventer/Controller inhaler?Select only one Only with my reliever (when required) When required Once a day Twice a day (or more) Weekly Fortnightly Monthly Other (not listed)How many inhaled puffs do you use with your Preventer/Controller inhaler?Select only one One puff Two puffs Three puffs Four puffs Five puffs Six puffs Seven puffs Eight puffs Nine puffs 10 puffs 10-20 puffs Over 20 puffs Other not listedCombination inhalerWhich Combination inhaler do you use?Select only onePlease selectAerivio (Fluticasone with salmeterol)AirfluSal Forspiro (Fluticasone with salmeterol)Aloflute (Fluticasone with salmeterol)Atectura (Mometasone furoate, indacaterol acetate)Combisal (Fluticasone with salmeterol)Dulera (Mometasone and formoterol)DuoResp Spiromax 160/4.5 (Budesonide with formoterol)DuoResp Spiromax 320/9 (Budesonide with formoterol)Enerzair Breezhaler (Glycopyronium bromide, indacterol acetate, mometasone furate)Flutiform 50/5 (Fluticasone propionate with formoterol)Flutiform 125/5 (Fluticasone propionate with formoterol)Flutiform 250/10 (Fluticasone propionate with formoterol)Flutiform K-haler 50/5 (Fluticasone propionate with formoterol)Flutiform K-haler 125/5 (Fluticasone propionate with formoterol)Fobumix Easyhaler 80/4.5 (Budesonide with formoterol)Fobumix Easyhaler 160/4.5 (Budesonide with formoterol)Fobumix Easyhaler 320/9 (Budesonide with formoterol)Fostair (NEXThaler) 100/6 (Beclometasone dipropionate (extrafine) with formoterol)Fostair (NEXThaler) 200/6 (Beclometasone dipropionate (extrafine) with formoterol)Fostair (pMDI) 100/6 (Beclometasone dipropionate (extrafine) with formoterol)Fostair (pMDI) 200/6 (Beclometasone dipropionate (extrafine) with formoterol)Fusacomb Easyhaler (Fluticasone with salmeterol)Orcibel (Fluticasone with salmeterol)Relvar Ellipta (Fluticasone with vilanterol)Sereflo (Fluticasone with salmeterol)Seretide Inhaler/Accuhaler (Fluticasone with salmeterol)Sidulpa (Fluticasone with salmeterol)Stalpex (Fluticasone with salmeterol)Symbicort Turbohaler 100/6 (Budesonide with formoterol)Symbicort Turbohaler 200/6 (Budesonide with formoterol)Symbicort Turbohaler 400/12 (Budesonide with formoterol)Trelegy Ellipta (Fluticasone furoate, umeclidinium bromide, vilanterol trifenate)Trimbow (Beclometasone diporpionate, formoterol fumarate, glycopyrronium bromide)Trixeo (Budesonide, formoterol fumarate dihydrate, glycopyrronium)Other (not listed)How frequently do you use your Combination inhaler?Select only one When required Once a day Twice a day (or more) Weekly Fortnightly Monthly Other (not listed)How many inhaled puffs do you use with your Combination inhaler?Select only one One puff Two puffs Three puffs Four puffs Five puffs Six puffs Seven puffs Eight puffs Nine puffs Ten puffs 10-20 puffs Over 20 puffs Other not listedAre you prescribed any other medication that you use regularly for your asthma?* Yes NoWhat other medication are you prescribed? Tablets InjectionsWhich tablet(s) are you prescribed? Steroids; Prednisolone, Dexamethasone, etc Aminophylline (Phyllocontin) Theophylline (Uniphyllin) Montelukast (Singulair) Zafirlukast (Accollate) Zileuton (Zyflo) OtherWhich injection(s) are you prescribed? Aminophylline Benralizumab (Fasenra) Dupilimab (Dupixent) Mepolizumab (Nucala) Omalizumab (Xoliar) Reslizumab (Cinqaero) OtherDo you have any allergies, eczema, and/or allergic rhinitis (allergies due to pollen, dust, etc)?* Yes NoHave you experienced an asthma attack/flare-up/exacerbation in the last 12 months, where you required further medical attention? Yes NoDo you have a valid photo ID, UK Driving license or Passport?* Yes NoHave you ever been diagnosed with anxiety or depression?* Yes NoAre you registered with a GP in the UK?* Yes NoDo you have any viral blood conditions such as HIV, Hepatitis A, B or C?* Yes NoAre you taking any medicines, either prescribed by a doctor, or bought from a chemist/pharmacy?*(This includes contraception, vitamins and supplements) Yes NoAre you currently suffering from any illness or health related condition?*(e.g. coughs & colds, stomach problems, chest complaints, dizziness, headaches, eczema etc.) Yes NoAre you or your partner pregnant or trying to get pregnant?* Yes NoAre you related to or employed by any member of hVIVO, FluCamp or Open Orphan?* Yes NoDo you have COPD as diagnosed by a doctor?* Yes NoWhich of our clinical sites would you like to attend for Visit 1?ChooseLondonManchesterAre you prepared to come to London for subsequent appointments?* Yes No
