Exhale-3 Study | Pre-Screener

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Compliance & Consent Statement

By checking the box below and submitting this form, you acknowledge that you have read and understood the questions above and have answered them to the best of your ability.

You understand that this is a pre-screening questionnaire and does not guarantee your enrollment in the clinical study. A member of the research team will contact you to discuss your answers and potentially schedule a formal screening visit at the clinic, where final eligibility will be determined.

Consent to be Contacted:

By checking this box, you provide your express written consent for the study site and its research partners to contact you regarding this asthma research study and other clinical trial opportunities that may be of interest. You agree to be contacted via automated and manual phone calls, text messages, and/or email at the phone number and email address you provide, even if your number is on a do-not-call list. You understand that your consent is not a condition of receiving any treatment and that you can withdraw your consent at any time.

I have read, understood, and agree to the statements above.

1. Are you 18 years old or older?

2. Have you been told by a doctor that you have had asthma for at least 1 year?

3. Do you currently use a daily inhaler (such as Advair, Symbicort, Breo, Dulera, or similar) to control your asthma?

4. In addition to your daily steroid inhaler, do you also use at least one other daily asthma medication?

5. In the past 12 months, have you had to see a doctor, urgent care, or emergency room for your asthma and been prescribed steroid pills, injections, or IV medicines (such as prednisone or methylprednisolone) to get it under control?

6. In the past 4 weeks, how often did you have asthma symptoms (such as coughing, wheezing, or shortness of breath) during the day?

7. In the past 4 weeks, how often did asthma wake you up at night or keep you from sleeping?

8. Do you currently smoke, vape, or use marijuana?

9. Are you currently pregnant, breastfeeding, or planning to become pregnant in the next few months?

10. Have you ever been told you have another lung condition, such as COPD, emphysema, pulmonary fibrosis, or cystic fibrosis?

11. To take part in this study, the research team will need permission to access your medical record — this helps confirm your history of asthma and ensures the study is a good fit for you. Are you comfortable allowing the study team to access your medical records for this purpose?

Compliance & Consent Statement

Consent to be Contacted:

Unfortunately, you have not met the pre-screening requirements for this study.

Congratulations, you’ve met the pre-screening requirements!