COPDM – Panacea Patient Recruitment

If you suffer from COPD attacks and it’s affecting your quality of life and are prepared to help, PLEASE FILL IN THE FORM BELOW and we’ll be in touch shortly (it takes less than 4 minutes to complete) THANKS…
1. Have you been diagnosed with COPD for more than 12 months?*
- Yes
- No
2. Have you been diagnosed with bronchitis (a chronic productive cough)?*
- Yes
- No
3. Do you also have a current diagnosis of Asthma?*
- Yes
- No

8. Do you have home oxygen that you use for more than 12 hours per day?*
- Yes
- No
9. Have you ever been diagnosed with any of the following?*
- Yes
- No
TB, Bronchiectasis, Sarcoidosis, Alpha-1-Antitrypsin deficiency Lung Fibrosis, Pulmonary hypertension, Interstitial Lung, Disease (ILD), Mesothelioma, Cystic Fibrosis (CF), Pneumoconiosis or Asbestosis
10. Have you ever been diagnosed with cancer other than a rodent ulcer?*
- Yes
- No

11. Have you ever been diagnosed with any of the following neurological conditions?*
- Yes
- No
Motor Neurone Disease (MND), a Stroke, Mini Stroke (Transient Ischemic Attack = TIA), Epilepsy
12.Have you ever been diagnosed with any of the following heart conditions?*
- Yes
- No
Unstable angina, Heart Failure, Atrial Fibrillation (AF), Artrial Flutter or had a Heart attack in the last 6 months

13. Have you ever been diagnosed with any of the following conditions?*
- Yes
- No
HIV, AIDS, Hepatitis B, Hepatitis C, Liver Cirrhosis, Multiple Sclerosis (MS), Lupus (SLE), Herpes Zoster (Shingles) or Herpes Simplex (Cold Sores)
14. Have you been treated with Roflumilast in the last 6 months?*
- Yes
- No

15. Have you used any of the following medications in the last 3 months?*
- Yes
- No
Methotrexate, Azathioprine, Infliximab, Etanercept, Humira, Herceptin, Avastin
16. Are you currently taking part in a clinical trial, or have you taken part in a clinical trial in the last 3 months?*
- Yes
- No

17.Sex*
- Male
- Female
17-2. Are you currently pregnant, breast feeding or actively trying to conceive a child - get pregnant?*
- Yes
- No
18. Do you have any history of alcohol abuse or drug abuse in the last 12 months?*
- Yes
- No
19. Do you have thoughts of suicide or made any attempts at suicide?*
- Yes
- No

If you suffer from COPD but are otherwise healthy and active and are prepared to help,

PLEASE COMPLETE FORM
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First Name*
Surname*
Date of Birth*
What is your height? Ft/in*
What is your weight? St/lb*
Contact Number*
Email*
Address*
Post Code*
Please note: If you test positive for drug abuse you will not receive any payments and you will be removed from the database.
Thank you for completing the online questionnaire. Please read and agree to our “privacy and special categories policy” before submitting your form.
Consent*
I have read and agreed to the Panacea Patient Recruitment “Privacy and Special Categories Policy.”
A team member will give you a telephone call shortly to tell you more about the trial and to answer any questions you may have.
Thanks