COPD Risk Factors Survey Form
Please complete this survey to help us understand factors that may be associated with COPD. This form is for informational purposes only and does not collect sensitive personal data.
What is your age group?
*
Please Select
Under 30
30-39
40-49
50-59
60 or older
What is your biological sex?
*
Male
Female
Prefer not to say
Have you ever smoked tobacco products?
*
Never
Former smoker
Current smoker
Are you regularly exposed to any of the following? (Select all that apply)
*
Air pollution (urban/industrial)
Secondhand smoke
Dust or chemicals at work
Indoor biomass fuels (wood, coal, etc.)
None of the above
Has anyone in your immediate family (parents or siblings) been diagnosed with COPD or chronic lung disease?
*
Yes
No
Not sure
How would you rate your physical activity level?
*
Very active
Moderately active
Somewhat active
Not active
Please indicate how often you experience the following symptoms:
*
Rows
Never
Rarely
Sometimes
Often
Cough
1
2
3
4
Shortness of breath
5
6
7
8
Wheezing
9
10
11
12
Mucus or phlegm
13
14
15
16
Have you ever been diagnosed with asthma or another chronic respiratory condition (not COPD)?
*
Yes
No
Not sure
How concerned are you about your risk for developing COPD?
*
Not concerned
1
2
3
4
Very concerned
5
1 is Not concerned, 5 is Very concerned
If you would like to share any additional relevant information, please do so below.
Submit Survey
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