The University of Arizona

ASTHMA RESEARCH REGISTRY INFORMATION FORM

University Of Arizona

Asthma Research Registry Information Form

At the University of Arizona and the Arizona Respiratory Center, there are a number of clinical research studies being conducted. The goal of this research, in general, is to gain new knowledge and to improve health care.

By completing this form, you are giving your permission for someone to contact you about our asthma research studies. You (or your child) will not be enrolled in clinical research without your knowledge or consent. Taking part in research is voluntary. Therefore, it is always up to you to decide if you want to take part.

Information you provide will be entered into our asthma research study database and will be stored on a secure University of Arizona server. Your information will not be shared with anyone or used for any other purpose other than to contact you about our asthma research studies.

Please answer the questions below about the person who has asthma.

Patient's Demographics
Patient's Medical History
Patient’s Medications
In the last year have you (or the patient):
Patient’s Smoking History
CAPTCHA
This question is for testing whether you are a human visitor and to prevent automated spam submissions.