This form cannot be submitted electronically at this time. Please use the Print button at the bottom of the page to print a copy, fill out the form manually and mail it to us at the above address.

Follow-up Information

First Name:		Last Name:		Today's Date:
Registration Date:		Identification Number:		Initials:
Date of Birth:		height(cm):		weight(kg):
Have you changed your smoking habits in the past year? Yes   No (If no, skip to medical history)
If yes, have you started smoking?          Stopped smoking?
If still smoking, cigarettes per day?      cigars per day?

Medical History (all questions refer to the past year)

Any new diagnosis:
Lung transplant?	Date:
Liver transplant?	Date:
Lung volume reduction?	Date:
Pneumonia?      number of times:
Have you had a CT of thorax this year(check if yes)?      Date:

Present Treatment

Have you been phenotyped this year?    date:
Indicate phenotype (if known)
Do you take medication for your lung disease? Yes     No
Are you on long term (more than 12 hours per day) oxygen treatment? Check if yes
Have you started on Prolastin in the past year?    date:
Have you stopped taking Prolastin in the last year?    date:
Are you aware of any abnormalities in your liver blood tests? Yes     No    date:
Were any elevated?   ALAT/SGOT    GGT   ASAT/SGPT   ALP/AP

Occupational Status

Are you presently working?    Yes    No

If no, did you have to quit this year due to your lung disease?    Yes    No

If you don't work, state the reason(s).     age   homemaker   other

Lung Function Test Results     Date of Last Test:

Pre-Bronchodilator (Ventolin):   FEV1 L:    FVC:    Slow VC:

Post ventolin:   FEV1 L:    FVC:    Slow VC:

Please include a copy of the lung function test if available. Thankyou.

Back to Registration Page