Section 1. You must answer yes, to all 3 question to be eligible for inclusion in the study.
| 1. Inclusion criteria: |
| Are you a smoker? |
| Are you over 35 years of age? |
| Are you willing to be tested again in 12 months and likely to be available? |
Section 2. Unfortunately, answering yes to either of the following questions means you cannot be included in the study.
| 2. Exclusions: |
| Are you on long term oxygen therapy or had part of a lung removed? |
| Have you been told you have lung cancer, lung TB(tuberculosis), bronchiectasis, asbestosis or silicosis? |
Section 3. Personal details will be for contact and identification purposes only. They are kept confidential and used only by authorised research staff.
| 3. Name, address and contact details |
| Surname |
| First name |
| Gender M/F |
| Date of Birth (dd/mmyyyy) |
| Age |
| Name of own GP |
| GP Surgery |
| Home or mobile telephone number and/or e-mail address (to contact you for follow up) |
Section 4. You will be asked about you past medical conditions. You can be included in the study if you have any of the following:
| 4. Past medical history |
| Has a doctor ever told you that you have any of the following condititions?... |
| Chronic bronchitis or ephysema (or COPD or COAD)? |
| Asthma? |
| Other lung disease? (please specify if known) |
| Stroke or CVA? |
| Angina or heart attack (myocardial infarction or ischaemic heart disease)? |
| Othe Heart disease? (please specify if know) |
| Diabetes? |
| Treatment for high blood pressure? |
Section 5. Smoking history
| 5. Please estimate the following. | number |
| How many years have you smoked? | |
| What is the average number cigarettes you have smoked per day? | |
| In the last 12 months how many times have you needed antibiotics for your chest? | |
| In the last 12 months how many times have you needed steroids for your chest? |
Section 6. This helps to compare different people at the start and end of the study. Answering yes or no to any section below will not exclude you from testing.
| 6. Intention to change (please tick yes or no to each question) | yes | no |
| Are you intending to quit smoking in the next 6 months? | ||
| Are you intending to quit smoking in the next month? | ||
| Did you try to quit smoking in the past year? |
