In order to receive monitoring services, you will need
to provide the following specific information:
Have you been diagnosed with COPD (Chronic Obstructive
Do you have: (check all that apply)
Do you use inhalers for your lung problem?
Please list your medications:
Medication/ Dose/How often
Have you ever used steroids (i.e., prednisone) for your
Have you ever been hospitalized for your COPD?
Have you ever been on a respirator as a result of your lung
Do you smoke?
Yes How much:
Have you smoked in the past?
If yes, how much did you smoke?
Pack per day
When did you stop?
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