Asthma Screening - Broward Pulmonary and Sleep Specialists

Asthma Clinical Trial Screening

Thank you for your interest in our asthma 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:

Have a physician diagnosis of asthma
Experience frequent exacerbations despite current treatment
Are on inhaler therapy

Patient Demographics

First Name *

Last Name *

Date of Birth *

Phone Number *

Email Address *

City

State / Zip Code

Height and Weight (approximate)

Asthma Diagnosis & History

Have you been diagnosed with asthma by a physician? * How many years ago were you diagnosed? How would you describe your asthma severity?

Exacerbation History

In the past 12 months, how many times did your asthma symptoms get significantly worse (exacerbation requiring treatment)? * In the past 12 months, how many times were you hospitalized or visited the ER for an asthma attack? In the past 12 months, how many times were you prescribed prednisone or other oral steroids for an asthma flare-up? In the past 12 months, how many times were you prescribed antibiotics for a respiratory infection?

Current Treatment

Are you currently using an inhaler? * What type of inhalers do you use? (check all that apply) Rescue inhaler (albuterol/ProAir/Ventolin)Inhaled corticosteroid (Flovent, Pulmicort, QVAR)Combination inhaler (Advair, Symbicort, Breo, Dulera)Long-acting bronchodilator (Serevent, Spiriva)Other List all current medications for asthma and other conditions Are you currently taking any biologic medications (injections such as Dupixent, Nucala, Fasenra, Xolair, Tezspire)?

Smoking History

What is your smoking status?

Allergies & Triggers

Do you have known allergies or triggers? (check all that apply) Dust mitesPollenPet danderMoldExerciseCold airSmokeStrong odors/chemicalsRespiratory infectionsNone identified

Research Participation

Are you currently participating in another research study?

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.