Download Baseline Respiratory Medication Use Questionnaire (RMU)

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).
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Respiratory Medication Use Questionnaire, RMU
Version 2.0 11/13/14
FORM 3
Page 3 of 3