Become a Member! In order to access our content, we ask that you please answer the following questions to create an account. This information helps us to measure the effectiveness of and make improvements to the program. Thank you for your cooperation. Please enable JavaScript in your browser to complete this form. - Step 1 of 4Name *FirstLastEmail *Date of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender *MaleFemalePhone Number (for emergencies only) *I am a.... *Person living with AsthmaPerson living with COPDPerson living with Alpha-1 Anti-Trypsin DeficiencyPerson living with Idiopathic Pulmonary Fibrosis (IPF)Person living with Pulmonary Fibrosis (PF) or other ILDPerson living with Pulmonary HypertensionCAREGIVER to someone living with respiratory diseaseHEALTH CARE professionalOther (please fill in below)Other (please fill in if selected above):I am: *Pre-TransplantPost-TransplantNeitherNext1. IN GENERAL, would you say your health is: *POORFAIRGOODVERY GOODEXCELLENT2. COMPARED TO ONE YEAR AGO, how would you rate your health in general now? *MUCH WORSESOMEWHAT WORSEABOUT THE SAMESOMEWHAT BETTERMUCH BETTER3. HOW MUCH DOES YOUR HEALTH LIMIT YOU, from vigorous activities, such as running, lifting heavy objects, participating in strenuous sports? *A LOTA LITTLENOT AT ALL4. HOW MUCH DOES YOUR HEALTH LIMIT YOU, from moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf? *A LOTA LITTLENOT AT ALL5. HOW MUCH DOES YOUR HEALTH LIMIT YOU, from lifting or carrying groceries? *A LOTA LITTLENOT AT ALL6. HOW MUCH DOES YOUR HEALTH LIMIT YOU, from climbing SEVERAL flights of stairs? *A LOTA LITTLENOT AT ALL7. HOW MUCH DOES YOUR HEALTH LIMIT YOU, from climbing ONE flight of stairs? *A LOTA LITTLENOT AT ALL8. HOW MUCH DOES YOUR HEALTH LIMIT YOU, from bending, kneeling, or stooping? *A LOTA LITTLENOT AT ALL9. HOW MUCH DOES YOUR HEALTH LIMIT YOU, from walking MORE THAN A MILE? *A LOTA LITTLENOT AT ALL10. HOW MUCH DOES YOUR HEALTH LIMIT YOU, from walking SEVERAL blocks? *A LOTA LITTLENOT AT ALL11. HOW MUCH DOES YOUR HEALTH LIMIT YOU, from walking ONE block? *A LOTA LITTLENOT AT ALL12. HOW MUCH DOES YOUR HEALTH LIMIT YOU, from bathing or dressing yourself? *A LOTA LITTLENOT AT ALL13. OVER THE PAST 4 WEEKS, as a result of your PHYSICAL HEALTH, Cut down the amount of time you spent on work or other activities? *YESNO14. OVER THE PAST 4 WEEKS, as a result of your PHYSICAL HEALTH, have you ACCOMPLISHED LESS than you would like? *YESNO15. OVER THE PAST 4 WEEKS, as a result of your PHYSICAL HEALTH, were you LIMITED IN THE KIND of work or other activities? *YESNO16. OVER THE PAST 4 WEEKS, as a result of your PHYSICAL HEALTH, did you have difficulty performing the work or other activities (for example, it took extra effort)? *YESNO17. OVER THE PAST 4 WEEKS, as a result of any EMOTIONAL problems (such as feeling depressed or anxious), have you cut down the amount of time you spent on work or other activities? *YESNO18. OVER THE PAST 4 WEEKS, as a result of any EMOTIONAL problems (such as feeling depressed or anxious), have you ACCOMPLISHED LESS than you would like? *YESNO19. OVER THE PAST 4 WEEKS, as a result of any EMOTIONAL problems (such as feeling depressed or anxious), did you not do work or other activities as carefully as usual? *YESNO20. OVER THE PAST 4 WEEKS, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups? *EXTREMELYQUITE A BITMODERATELYSLIGHTLYNOT AT ALL21. OVER THE PAST 4 WEEKS, how much SHORTNESS OF BREATH (SOB) have you had? *VERY SEVERESEVEREMODERATEMILDVERY MILDNONE22. OVER THE PAST 4 WEEKS, how much did shortness of breath (SOB) interfere with your normal work (including both work outside the home and housework)? *EXTREMELYQUITE A BITMODERATELYA LITTLE BITNOT AT ALL23. OVER THE PAST 4 WEEKS, how often did you feel full of PEP? *NONE OF THE TIMEA LITTLE OF THE TIMESOME OF THE TIMEA GOOD BIT OF THE TIMEMOST OF THE TIMEALL THE TIME24. OVER THE PAST 4 WEEKS, how often have you been a very nervous person? *NONE OF THE TIMEA LITTLE OF THE TIMESOME OF THE TIMEA GOOD BIT OF THE TIMEMOST OF THE TIMEALL THE TIME25. OVER THE PAST 4 WEEKS, how often have you felt so down in the dumps that nothing could cheer you up? *NONE OF THE TIMEA LITTLE OF THE TIMESOME OF THE TIMEA GOOD BIT OF THE TIMEMOST OF THE TIMEALL THE TIME26. OVER THE PAST 4 WEEKS, how often have you felt calm and peaceful? *NONE OF THE TIMEA LITTLE OF THE TIMESOME OF THE TIMEA GOOD BIT OF THE TIMEMOST OF THE TIMEALL THE TIME27. OVER THE PAST 4 WEEKS, how often did you have a lot of energy? *NONE OF THE TIMEA LITTLE OF THE TIMESOME OF THE TIMEA GOOD BIT OF THE TIMEMOST OF THE TIMEALL THE TIME28. OVER THE PAST 4 WEEKS, how often have you felt downhearted and blue? *NONE OF THE TIMEA LITTLE OF THE TIMESOME OF THE TIMEA GOOD BIT OF THE TIMEMOST OF THE TIMEALL THE TIME29. OVER THE PAST 4 WEEKS, how often did you feel worn out? *NONE OF THE TIMEA LITTLE OF THE TIMESOME OF THE TIMEA GOOD BIT OF THE TIMEMOST OF THE TIMEALL THE TIME30. OVER THE PAST 4 WEEKS, how often have you been a happy person? *NONE OF THE TIMEA LITTLE OF THE TIMESOME OF THE TIMEA GOOD BIT OF THE TIMEMOST OF THE TIMEALL THE TIME31. OVER THE PAST 4 WEEKS, how often did you feel tired? *NONE OF THE TIMEA LITTLE OF THE TIMESOME OF THE TIMEA GOOD BIT OF THE TIMEMOST OF THE TIMEALL THE TIME32. OVER THE PAST 4 WEEKS, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)? *NONE OF THE TIMEA LITTLE OF THE TIMESOME OF THE TIMEMOST OF THE TIMEALL THE TIME33. HOW TRUE OR FALSE IS IT THAT, you seem to get sick a little easier than other people? *DEFINITELY TRUEMOSTLY TRUEDON'T KNOWMOSTLY FALSEDEFINITELY FALSE34. HOW TRUE OR FALSE IS IT THAT, you are as healthy as anybody you know? *DEFINITELY TRUEMOSTLY TRUEDON'T KNOWMOSTLY FALSEDEFINITELY FALSE35. HOW TRUE OR FALSE IS IT THAT, you expect your health to get worse? *DEFINITELY TRUEMOSTLY TRUEDON'T KNOWMOSTLY FALSEDEFINITELY FALSE36. HOW TRUE OR FALSE IS IT THAT, your health is excellent? *DEFINITELY TRUEMOSTLY TRUEDON'T KNOWMOSTLY FALSEDEFINITELY FALSEBackNextWelcome to Pulmonary Wellness Online!These terms and conditions outline the rules and regulations for the use of Pulmonary Wellness Online by Pulmonary Wellness Foundation and Pulmonary Wellness Rehabilitation PTPC. By accessing this website and its content, you understand and acknowledge that you accept these terms and conditions in full. If you do not accept all of these terms and conditions in full, please discontinue use immediately or do not initiate use. Medical DisclaimerPlease review and agree to the following disclaimers by checking the boxes below:TS1 *By accessing this website and its content, you understand and acknowledge that any and all information provided, online or otherwise, by Pulmonary Wellness Online or any of its associates or affiliates is general in nature. As such, it is not, nor is it intended, for the purposes of providing, or as a substitute or replacement for the advice, instruction, consultation, diagnosis and treatment by your personal physician, medical professional, health care provider or member of your health care team.TS2 *You understand and acknowledge that you have consulted with, and been medically cleared by your personal physician for participation in Pulmonary Wellness Online.TS3 *You understand and acknowledge that although rare, the implementation of any lifestyle change, including medical, physical, behavioral, psychological or other comes with certain inherent known and unknown medical, physical, behavioral, psychological, or other potential risks and you assume full responsibility for such risks.TS4 *You further understand and acknowledge that: should any medical and/or health-related questions arise, particular to your own personal health and wellbeing, that it is your personal responsibility to promptly contact and consult your personal physician, medical professional, health care provider or member of your health care team.TS5 *You understand and acknowledge that you are participating in Pulmonary Wellness Online voluntarily and entirely at your own risk. You further understand and acknowledge that you assume all risks, both known and unknown, related to you or your participation in Pulmonary Wellness Online.TS6 *You understand and acknowledge that in the event of a medical incident or emergency, it is your responsibility to contact your physician, health care provider, local 911 or Emergency Medical Services (EMS) system.Please type your name below to confirm you have carefully reviewed and agree to the above Terms and Conditions: *BackNextSafety and That Little Waiver You Signed! Orientation: Safety and That Little Waiver You Signed! Please type your name to verify you have watched the full safety video: *CommentLast Step
