COPD Screening

COPD Clinical Trial Screening

Thank you for your interest in our COPD clinical research studies. Please complete the screening form below and our research team will review your information and contact you to discuss potential study opportunities.

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You may be eligible if you:

Are between 40 and 85 years of age
Have been diagnosed with COPD for at least 1 year
Have had 1 or more flare-ups (episodes where your breathing got significantly worse, requiring steroids like prednisone or antibiotics) in the past 12 months, or at least 1 hospitalization for COPD
Are a current or former smoker with at least 10 pack-years of smoking history (1 pack-year = smoking 1 pack per day for 1 year; for example, 1 pack/day for 10 years = 10 pack-years)
Are currently on inhaler therapy — preferably triple therapy: a combination of three types of inhalers (e.g., Trelegy, Breztri, or three separate inhalers)

Patient Demographics

First Name *

Last Name *

Date of Birth *

Phone Number *

Email Address *

City

State / Zip Code

Height and Weight (approximate)

COPD Diagnosis & History

Have you been diagnosed with COPD (Chronic Obstructive Pulmonary Disease) by a physician? * How many years ago were you diagnosed? Have you ever been diagnosed with asthma?

Flare-Up History

A flare-up (also called an exacerbation) is when your COPD symptoms suddenly get much worse — more shortness of breath, more coughing, or more mucus than usual — often requiring extra treatment.

In the past 12 months, how many times did your COPD symptoms flare up significantly, requiring treatment with oral steroids (e.g., prednisone) or antibiotics? * In the past 12 months, how many times were you hospitalized or visited the ER for a COPD flare-up (staying more than 24 hours)? In the past 12 months, how many times were you prescribed prednisone or other oral steroids for a COPD flare-up? In the past 12 months, how many times were you prescribed antibiotics for a respiratory infection or COPD flare-up?

Current Treatment

Are you currently using triple inhaler therapy? This means using three types of inhalers together: an inhaled steroid + a long-acting bronchodilator + a long-acting muscarinic agent (e.g., Trelegy, Breztri, or three separate inhalers). How long have you been on your current inhaler regimen? List all current medications for COPD and other conditions Are you currently taking any biologic medications? These are specialty injections such as Dupixent, Nucala, Fasenra, Xolair, or Tezspire.

Smoking History

What is your smoking status? * Approximately how many years did you smoke, and how many cigarettes per day on average? (Pack-years = packs per day × years smoked. Example: 1 pack/day for 20 years = 20 pack-years)

Oxygen Use

Do you use supplemental oxygen?

Other Medical History

Do you have any of the following lung conditions? (check all that apply) Pulmonary fibrosis (scarring of the lungs)Bronchiectasis (damaged, widened airways)Sarcoidosis (inflammatory lung disease)Pulmonary hypertension (high blood pressure in the lungs)Alpha-1 antitrypsin deficiency (inherited lung condition)Cystic fibrosisLung cancerNone of the above Have you had a heart attack, stroke, or been hospitalized for heart problems in the past 6 months? Do you have advanced heart failure (NYHA Class III or IV)? This means you are comfortable only at rest and experience symptoms like shortness of breath or fatigue with minimal activity or even while resting. Have you ever been treated for tuberculosis (TB)? Do you have significant liver disease (cirrhosis or liver failure)? Have you had any major surgery in the past 4 weeks, or do you have surgery planned? Do you have an autoimmune disease (e.g., rheumatoid arthritis, lupus)? Have you ever had lung surgery (lung removal, lung volume reduction, or lung transplant)?

Research Participation

Are you currently participating in another research study? Have you participated in a clinical trial in the past 6 months?

Consent

I consent to being contacted about research participation and acknowledge that my information will be handled in accordance with HIPAA regulations.

Questions? Call our research line: (954) 520-7296

Submitting this form does not guarantee enrollment in a clinical trial. All studies are conducted under strict regulatory oversight and ethical guidelines.