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RESPIRATORY MEDICATION USE QUESTIONNAIRE Visit Number COPDGene NUMBER: PIE # THIS FORM DOES NOT NEED TO BE COMPLETED IF THE SUBJECT IS WITHIN WINDOW FROM COPDGene VISIT 0a) Date…………… / / 0b) Initials ........... Instructions: This form should be completed during the participant’s visit. Whenever numerical responses are required, enter the number so that the last digit appears in the rightmost box. 0c) Have you changed any medication since your COPDGene visit 2?...Yes Go to Question #1 No End NA Go to Question #1 The following questions ask what medications you currently take. 1) Are you currently using theophylline (Uniphyl, Theo-24, Theochron, Theolair)? (Y/N) ............. 2) Are you currently using oral corticosteroids: daily or chronic (prednisone, Medrol, Deltasone, prednisolone)? (Y/N) ............................................................. 3) Do you use supplemental oxygen therapy? (Y/N) ..................................................................... 3a) When do you use supplemental oxygen? Mark all that apply At rest….. During exercise….. During sleep….. 3b) How long have you used supplemental oxygen?............................................................ 3c) Approximately how many hours in a 24 hour period?........................................ years hours per day 4) Do you currently use a nebulizer for an inhaled medication? (Y/N) .......................................... 5) Do you currently use an inhaled short-acting beta-agonist? ? (Y/N) .......………………………… (AccuNeb, Albuterol, Maxair, ProAir, Proventil, Ventolin, Xopenex) Respiratory Medication Use Questionnaire, RMU Version 2.0 11/13/14 FORM 3 Page 1 of 3 Visit Number COPDGene NUMBER: PIE # 6) Do you currently take Ipratropium bromide? (Atrovnet) ? (Y/N) …………………………………. 7) Do you currently take a combination short-acting inhaled medication? ? (Y/N)………………… (albuterol and ipratropium bromide, Combivent, DuoNeb) 8) Do you currently take a long-acting beta-agonist? ? (Y/N)………………………………………… (Arcapta, Brovna, Foradil, formoterol, Perforomist solution) 9) Are you currently using an antimuscarinic bronchodilator? ? (Y/N)………………………………. (aclidinium, Spirivia, tiotropium, Tudorza) 10) Are you currently using an inhaled corticosteroid? ? (Y/N)………………………………………… (Aerobid, Aerospan, Asmanex, Azmacort, Flovent, Pulmicort, Pulmicort Respules, Qvar) 11) Are you currently using a combination inhaled corticosteroid + long-acting beta-agonist? (Y/N)……………………………………………………………………………………... (Advair, Dulera, Symbicort) 12) How many puffs a day of your short-acting rescue inhaled have you taken in the past week? 4 or fewer 5-10 10 or more 13) Do you use a macrolide antibiotic: daily or chronic? (Y/N)…………………………………….……. (azithromycin, Zithromax, Zmax) 14) Do you use a phosphodiesterase inhibitor? (Y/N)…………………………………………..………. (Daliresp, roflumilast) Respiratory Medication Use Questionnaire, RMU Version 2.0 11/13/14 FORM 3 Page 2 of 3 Visit Number COPDGene NUMBER: PIE # 16) Do you use medication for osteoporosis (thin bones)? (Y/N)………………………………………. If YES, then which medication do you take? Mark all that apply. Bone anti-resorption medication: Actonel, Boniva, Fosamax, Reclast Calcitonin: Calcimar, Fortical, Miaclacin Calcium or vitamin D Estrogen or hormone replacement therapy (pills, patches, creams) Parathyroid hormone: Forteo, teriparatide Selective estrogen modulator: Evista, raloxifene Testosterone (injections, gels) 17) Do you take medication for rheumatoid arthritis? (Y/N)…………………………………..………. If YES, then which medication do you take? Mark all that apply. Biological agent: Enbrel, Humira, Remicade Disease-modifying antirheumatic drug: Arava, Azulfidine, Immuran, methotrexate, Plaquenil Nonsteroidal anti-inflammatory drug: Advil, Aleve, Celebrex, ibuprofen, Motrin, Naprosyn Steroid: Medrol, methylprednisolone, prednisolone, prednisone 18) List all medications, including those for you lungs, you take that have been prescribed by your health care provider (physician, nurse practitioner, physician assistant). ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Respiratory Medication Use Questionnaire, RMU Version 2.0 11/13/14 FORM 3 Page 3 of 3
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