Asthma Study Post Survey

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone *

Date / Time *

Date

Time

This questionnaire has been designed to provide information as to how your Asthma is affecting your ability to manage in everyday life. Please answer by checking ONE box in each section for the statement which best applies to you. We realize you may consider that two or more statements in any one section apply but please just select one that indicates the statement which most clearly describes your problem.

1 – In the past 4 weeks, how much of the time did your Asthma keep you from getting as much done at work, school or at home? *

2 – During the past 4 weeks, how often have you had shortness of breath? *

3 – During the past 4 weeks, how often did your Asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in the morning? *

4 – During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)? *

5 – How would you rate your Asthma control during the past 4 weesks? *

6 – On average, how many times a week did you use the device? *

7 – On average, do you feel you were properly hydrated before each session? (Hydrated = a liter of water in the preceding 4 hours before a session) *

1 – Yes
2 – No

Did you experience any side effects from the therapy? (None have been reported in the past, but we want to make sure.)

In your own words, how did the Pulsar XO help with your Asthma? *

Cart

Asthma Study Post Survey

Support

Our Policy

Store Information