In order to receive monitoring services, you will need to provide the following specific information:

Have you been diagnosed with COPD (Chronic Obstructive Pulmonary Disease)?
Yes
No

Do you have: (check all that apply)
Emphysema
Chronic bronchitis
Other
Do you use inhalers for your lung problem?
Yes
No

Please list your medications:
Medication/ Dose/How often


Have you ever used steroids (i.e., prednisone) for your COPD?
Yes
No

Have you ever been hospitalized for your COPD?
Yes
No

Have you ever been on a respirator as a result of your lung problems?
Yes
No

Do you smoke?
Yes  How much:
No

Have you smoked in the past?
Yes  

If yes, how much did you smoke?
Pack per day
Years

When did you stop?
Years ago
No