Question 1/14

Have you been diagnosed with Chronic Bronchitis

Yes
No

Question 2/14

Do you have any of the following?

Question 3/14

Do you smoke?

Yes
No
I quit

Question 4/14

Do you get annual flu vaccinations?

Yes
No

Question 5/14

Have you gotten pneumonia vaccination?

Yes
No

Question 7/14

Are you currently satisfied with your treatment?

Yes
No

Question 8/14

Please explain why are you dissatisfied with your current treatment

Question 9/14

Are you interested in changing your treatment?

Yes
No

Question 10/14

What treatment(s) are you interested in switching to

Question 11/14

Do you currently have medical insurance?

Yes
No

Question 12/14

Please select your current medical provider

Question 13/14

What is the name of your provider?

Question 14/14

lease select the current medical coverage you have