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Lung Health Cohort Screening Survey

Duke Pulmonary Medicine is currently recruiting male and female volunteers (25 - 35 years of age) for a study called Lung Health Cohort (LHC).

This research is being done to find out why some people have better lung function than others as young adults during the period of peak lung health (ages 25 to 35 years old). This will allow us to come up with ideas about how to promote the best possible lung function in adults and also prevent and treat lung diseases like asthma, chronic obstructive pulmonary disease (COPD, also called emphysema or bronchitis), pulmonary fibrosis (scarring in the lungs), and lung cancer.

The survey below will ask you a few basic questions to assist us in contacting you to inform you about the study and to confirm you meet certain study criteria. If you prefer, we can also ask you the survey questions over the phone and complete the survey for you.

Completion of the survey also means that your information will be seen by members of the Duke Pulmonary Medicine research team. The only risk to you is the risk of loss of confidentiality. However, all of the individuals who will see your information are trained professionals who work with healthcare information daily and are aware of the importance of maintaining confidentiality of health records. Your personal Information will be stored securely and can be withdrawn at any time.

Based on your survey responses, if you meet study criteria for the Lung Health Cohort study, we will contact you to schedule a screening visit.

For questions or more information please call the Duke Airway Research Group at 919-479-0861.

To be considered for the LHC study, please complete the survey below.

Thank you!

Today's Date

M-D-Y

First Name

* must provide value

Middle Initial

Last Name

* must provide value

Date of Birth

* must provide value

M-D-Y

Age

View equation

Preferred Phone Number

* must provide value

Preferred Email Address

Preferred Method of Contact

Phone

Text

Mailing Address

* must provide value

Assigned Sex at Birth

* must provide value

Female

Male

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Race

* must provide value

Alaskan Native or American Indian

Asian

Black or African American

Native Hawaiian or Pacific Islander

White

Other

Ethnicity

* must provide value

Hispanic

Non-Hispanic

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Height

* must provide value

Weight

* must provide value

Body Mass Index (BMI)

View equation

Are you currently taking any medications?

This includes prescribed medicines, over the counter (OTC) preparations, vitamins and health supplements, birth control and ADHD medications.

* must provide value

Yes

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Types of medications

* must provide value

Over the counter

Vitamins or nutrition supplements

Birth Control (females only)

Prescriptions medications

Please list medications

Do you have a history of any heart or lung condition?

* must provide value

Yes

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Please describe

Do you have a history of cancer other than non-melanoma skin cancer

Yes

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Please describe:

Are you currently diagnosed with asthma?

* must provide value

Yes

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Are you prescribed an inhaled corticosteroid medication (ICS) or combination therapy with two medications

* must provide value

Yes

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Provide asthma medication name and dosages

Do you have any other medical conditions NOT described above?

* must provide value

Yes

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Please describe

Yes

Have you had 3 or more unscheduled healthcare visits (provider/urgent care/ emergency room) for asthma in the last 12 months?

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Have you been hospitalized for asthma in the past 12 months?

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Are you pregnant or presently lactating?

* must provide value

Yes

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Are you a college or graduate student or employee under direct supervision of any of the investigators in this protocol?

* must provide value

Yes

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If you are a healthy volunteer not yet signed up for our Pulmonary Medicine Healthy Volunteer Data Repository to be contacted for future studies, would you like to be added?

Yes

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Click this link: Pulmonary Medicine HVDR

If you have a lung health problem and are not currently signed up for our Pulmonary Medicine Lung Disease Data Repository to be contacted for future studies, would you like to be added?

* must provide value

Yes

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Click this link: Pulmonary Medicine LDVDR

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.