Patient Questionaire
	It’s easy to see if you qualify for one of our enrolling studies. Please complete the questionnaire and you will be contacted to discuss our available studies. To review our privacy policy click here. First Name: Last Name: Address 1: Address 2: (optional) City: State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AA AE AP AS PR FM GU MH MP PW VI Zip Code:   Date of Birth:        Email:   Home Telephone:        Mobile Telephone: (optional)        Work Telephone: (optional)
	Medical Condition
	Are you a smoker? Yes No If Yes, How many packs per day? Please Choose 01 02 03 04 05 6 or more Medical History Current Medications   Select Area of Interest: Asthma COPD Allergy Influenza