Bronchiectasis Screening

Bronchiectasis Clinical Trial Screening

Thank you for your interest in our bronchiectasis 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 18 and 85 years of age
Have a confirmed diagnosis of bronchiectasis (by CT scan within the past 5 years)
Produce mucopurulent sputum chronically
Have had 2 or more exacerbations requiring antibiotics in the past 12 months, or at least 1 hospitalization
Do not have cystic fibrosis

Patient Demographics

First Name *

Last Name *

Date of Birth *

Phone Number *

Email Address *

City

State / Zip Code

Height and Weight (approximate)

Bronchiectasis Diagnosis & History

Have you been diagnosed with bronchiectasis by a physician? * How was your bronchiectasis confirmed? How many years ago were you diagnosed? Do you have a chest CT scan within the past 5 years confirming bronchiectasis? Do you have cystic fibrosis? *

Symptoms & Exacerbation History

Do you cough up phlegm or sputum daily? * If yes, what color is your sputum most of the time? In the past 12 months, how many times did your bronchiectasis symptoms get significantly worse (exacerbation requiring treatment)? * In the past 12 months, how many times were you hospitalized or visited the ER for a respiratory infection or bronchiectasis flare-up? In the past 12 months, how many times were you prescribed prednisone or other oral steroids for a bronchiectasis flare-up? In the past 12 months, how many times were you prescribed antibiotics for a respiratory infection or bronchiectasis flare-up?

Current Treatment

Are you currently on long-term or maintenance antibiotics? If on maintenance antibiotics, have you still had exacerbations while on them? List all current medications Are you currently taking any biologic medications (injections such as Dupixent, Nucala, Fasenra, Xolair, Tezspire)?

Smoking History

What is your smoking status?

Other Medical History

Do you have any of the following conditions? (check all that apply) Known immunodeficiency disorderCurrently being treated for tuberculosis (TB)Allergic bronchopulmonary aspergillosis (ABPA)Unstable heart disease or heart attack in past yearSignificant hemoptysis (coughing blood) in past 6 weeksNone of the above

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.