Asthma Study Volunteer Application

1Tell us about yourself

2Height and Weight

3Your Asthma

4Your lifestyle & status

Name*

Gender*

Male

Female

Date of Birth*

To be eligible you must be within the ages of 18 and 65 to apply

Your email address*

Best contact number*

Maximum of 11 digits. Avoid spaces. (e.g. 07912345678 or 02077561414)

Address Line 1*

Address Line 2

Address Line 3

County

City

Postcode*

Height (in cm)*

Weight (in kg)*

Hidden

BMI

Have you been diagnosed with asthma more than 6 months ago?*

Yes

Are you prescribed an inhaler to treat your asthma?*

Yes

Which inhaler(s) are you prescribed?*

You can select more than one option

Reliever

Preventer/Controller inhaler

Combination inhaler

Reliever

Which Reliever do you use?*

Select only one

How frequently do you use your chosen Reliever?*

Select only one

Preventer/Controller inhaler

Which Preventer/Controller inhaler do you use?*

Select only one

How frequently do you use your Preventer/Controller inhaler?*

Select only one

How many inhaled puffs do you use with your Preventer/Controller inhaler?*

Select only one

Combination inhaler

Which Combination inhaler do you use?*

Select only one

How frequently do you use your Combination inhaler?*

Select only one

How many inhaled puffs do you use with your Combination inhaler?*

Select only one

Are you prescribed any other medication that you use regularly for your asthma?*

Yes

What other medication are you prescribed?

Tablets

Injections

Which tablet(s) are you prescribed?

Which injection(s) are you prescribed?

Do you have any allergies, eczema, and/or allergic rhinitis (allergies due to pollen, dust, etc)?*

Yes

Have you experienced an asthma attack/flare-up/exacerbation in the last 12 months, where you required further medical attention?

Yes