Please complete the questionnaire below so that we may determine if you qualify to participate in any of our current or planned research studies.

If you wish, you may select the "Submit" option when you are done to send this form to us by e-mail.

If you do not wish to e-mail your responses, you may print your completed form directly from your browser and mail or fax it back. Our mailing address is: Colorado Allergy and Asthma Centers, P.C., 125 Rampart Way, Suite #150, Denver, CO 80230. Our fax number is (720) 858-7530.

If it appears that you are a good candidate for an upcoming study, we will ask you to schedule a short visit (15-30 minutes) to measure your lung functions and determine the study(ies) for which you may be eligible. If you are not currently eligible for a study, we will keep your information in our database until an appropriate study becomes available unless you tell us you want your information deleted.

Any information you provide is protected by the Health Insurance Portability and Accountability Act (HIPAA) of 2001. Your information will not be sold or given to any party outside Colorado Allergy & Asthma Centers, PC.

Thank you for your time and interest in completing this questionnaire. We look forward to meeting and working with you!
Basic Information

* = Required Field

*Name (last, first, MI):


E-mail Address:


Mailing Address:


City:


State:


Zip Code:


*Phone Number:
Gender:
Male
Female
Office Preference:
Centennial
Denver
Lakewood
Check the symptoms that apply to you:
Allergy
Asthma
Sinusitus
Migraine Headache
If you checked Allergy Symptoms, when do they occur?
Spring
Fall
All Year
To what allergens are you allergic?
Ragweed
Dust
Animals
Molds
Other
For Asthma Symptons, please check the type of steroids you use:
Inhaled-steroids
Oral-steroids
Combination Medications
None
Smoking History:
Past
Current
Never
How would you like use to contact you?
Phone
Email
Either
 

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