Patient Intake Survey

Section 1 of 11

About You

These basic questions help us understand who is completing this survey so we can identify patterns across different communities and life stages.

Q1. How old are you?

Q2. What is your gender?

Man

Woman

Non-binary / gender-diverse

Prefer not to say

Q3. What is the highest level of education you have completed?

Q4. Which of the following best describes your current living situation?

I live alone

I live with a spouse or partner

I live with family members (not a spouse/partner)

I live with a paid caregiver or in assisted living

I live with roommates

Q5. How would you describe where you live?

Urban / city

Suburban

Rural / small town

Very remote (limited access to services)

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Section 2 of 11

Your Respiratory Condition

Tell us about your condition — what you've been diagnosed with, how long you've been living with it, and what tools or treatments are part of your daily life.

Q6. Which respiratory conditions have you been diagnosed with? Select all that apply

Q7. How long have you been living with your primary respiratory condition?

Q8. Do you currently use any of the following? Select all that apply

CPAP machine

BiPAP machine

Home oxygen (concentrator or tanks)

Nebulizer

Rescue / short-acting inhaler

Maintenance / long-acting inhaler

Airway clearance device (vest, flutter, acapella, etc.)

Pulse oximeter (at-home oxygen monitor)

I do not currently use any of these

Q9. What stage or severity has your doctor told you about?

Q10. How many times have you been hospitalized due to your respiratory condition in the past 12 months?

0 times

1 time

2 times

3 or more times

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Section 3 of 11

Your Diagnosis Journey

We want to understand what it was like to learn about your condition — the path you took to get a diagnosis and how you were supported during that process.

Q11. How long did it take from when you first noticed symptoms to when you received a formal diagnosis?

Q12. How many different doctors or providers did you see before receiving your diagnosis?

Q13. When you were first diagnosed, how well did your doctor explain your condition to you?

Very well — I understood everything clearly

Somewhat well — I understood the basics

Not very well — I had many questions left unanswered

Poorly — I left more confused than when I came in

I wasn't given much explanation at all

Q14. In your own words, what was it like to receive your diagnosis? What do you wish had been different about that experience? Take as much space as you need. Your story matters.

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Section 4 of 11

Symptoms and Daily Challenges

These questions help us understand how your condition affects your everyday life. Based on concepts from the COPD Assessment Test (CAT) and mMRC Dyspnea Scale.

Q15. Overall, how much do breathing difficulties affect your daily activities?

Not at all — I do everything I want to do

A little — I occasionally need to slow down or modify activities

Moderately — I avoid some activities because of breathing

A lot — My breathing significantly limits what I can do

Severely — I am unable to do most activities due to breathing

Q16. How often do you experience each of the following symptoms?

Symptom	Never	Rarely	Sometimes	Often	Almost always
Shortness of breath
Persistent cough
Wheezing or chest tightness
Excess mucus or phlegm
Fatigue or low energy
Difficulty sleeping
Dizziness or lightheadedness

Q17. How has your condition affected each of these activities?

Activity	Not at all	A little	Moderately	A lot	Can't do
Walking short distances
Climbing stairs
Personal care (bathing, dressing)
Light household chores
Social activities / time with others
Hobbies or recreation
Working or volunteering

Q18. Describe a typical "bad day" with your respiratory condition. What happens, and how does it affect you?

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Medications and Treatment

These questions are about how you manage your treatments. There are no right or wrong answers — we just want to understand your real, day-to-day experience.

Q19. How many prescription medications do you currently take for your respiratory condition?

Q20. How often do you take your medications exactly as prescribed?

Always — I never miss a dose

Most of the time — I occasionally miss a dose

Sometimes — I miss doses fairly often

Rarely — I often don't take medications as prescribed

I have stopped taking some or all of my medications

Q21. What are the main reasons you sometimes skip or stop taking your medications? Select all that apply — skip this question if you always take your medications as prescribed

I forget

The medication is too expensive

Side effects bother me

I don't feel like it's helping

It's hard to use the inhaler or device correctly

My breathing feels okay so I think I don't need it

I ran out and couldn't get a refill quickly enough

The routine is too complicated

I don't fully understand why I need it

Q22. If you use a CPAP or BiPAP, how often do you use it as prescribed?

Q23. What is the single biggest barrier to consistently using your respiratory treatments?

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Section 6 of 11

Education After Diagnosis

We want to understand what information and support you received — and what was missing — after your diagnosis.

Q24. After your diagnosis, were you referred to any of the following? Select all that apply

Pulmonary rehabilitation program

Respiratory therapist

Disease management program or class

Smoking cessation program

Mental health or counseling services

Peer support group (in person or online)

Social work or care coordination

I was not referred to any of these

Q25. Did you attend or complete pulmonary rehabilitation?

Yes, I completed a full program

Yes, I attended some sessions but didn't finish

I was referred but couldn't access it (cost, transportation, scheduling)

I was referred but chose not to go

I was never referred to pulmonary rehab

I didn't know pulmonary rehab existed

Q26. After your diagnosis, how well did you feel prepared to manage your condition at home?

Very well prepared

Somewhat prepared

Not very prepared

Not at all prepared — I felt lost

Q27. What information do you wish you had received earlier in your care journey? What would have made the biggest difference?

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Quality of Life

These questions use concepts from internationally validated quality-of-life measures (PROMIS Global Health, EQ-5D) adapted for plain language.

Q28. In the past 4 weeks, how would you rate your overall quality of life?

Q29. In the past 4 weeks, how much has your respiratory condition limited your independence — your ability to do things on your own schedule and terms?

Not at all — I can mostly do what I want, when I want

A little — I occasionally adjust plans because of my breathing

Moderately — I regularly make compromises

A great deal — my condition shapes most of what I can do

Completely — it has taken over nearly all of my decisions

Q31. Has your respiratory condition affected your ability to work?

No, I can work normally

Yes, I've had to reduce my hours or responsibilities

Yes, I had to stop working entirely because of my condition

Yes, I've had to change careers or roles

I was not working prior to my diagnosis

I am retired

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Section 8 of 11

Mental Health and Emotional Well-Being

Chronic illness affects more than just physical health. These questions explore your emotional experience. They are based on PHQ-2 and GAD-2 screening concepts. There are no wrong answers — only honest ones.

Q32. Over the past 2 weeks, how often have you felt down, depressed, or hopeless because of your condition?

Not at all

Several days

More than half the days

Nearly every day

Q33. Over the past 2 weeks, how often have you felt nervous, anxious, or on edge about your breathing or health?

Not at all

Several days

More than half the days

Nearly every day

Q34. How has your respiratory condition affected your emotional well-being? Select all that apply

I worry constantly about whether my condition will get worse

I feel isolated or lonely because of my limitations

I feel frustrated or angry about my situation

I feel like a burden to my family or caregivers

I've experienced grief over things I can no longer do

I feel embarrassed about using equipment (oxygen, inhaler) in public

I feel anxious every time I have a breathing episode

I feel mostly at peace with my situation

Q35. Have you ever talked to a provider about your mental or emotional health in the context of your condition?

Yes, and it was helpful

Yes, but it didn't feel very helpful

No, but I would have welcomed that conversation

No — I don't feel my emotional health is related to my condition

No — my providers never asked

Q36. In your own words, how has living with a chronic respiratory condition changed you emotionally or mentally? What do you want others to understand?

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Section 9 of 11

Caregivers and Your Support Network

Many patients rely on family, friends, or professional caregivers. This section helps us understand how care and support actually work in real life.

Q37. Do you have a primary caregiver or someone who regularly helps you manage your health?

Yes, a spouse or partner

Yes, an adult child or other family member

Yes, a friend

Yes, a professional or paid caregiver

No, I manage my condition primarily on my own

I have informal support but no single primary caregiver

Q40. What do you wish your caregivers, family, or friends better understood about your condition and your experience?

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Section 10 of 11

Your Healthcare Frustrations

We know these questions can be hard to answer. Your honest perspective here is one of the most meaningful things you can share — it's what Nevidra carries into the rooms where healthcare decisions get made.

Q41. What are your biggest frustrations with the healthcare system as a respiratory patient? Select all that apply

Q42. On a scale of 1–10, how well does your current healthcare team understand your day-to-day experience of living with your condition? 1 = They have no idea what my daily life is like · 10 = They truly understand my full experience

They have no idea

Fully understand

Q43. Have you ever felt dismissed, minimized, or not believed by a healthcare provider regarding your symptoms?

Yes, frequently

Yes, occasionally

Rarely

Never

Q44. Describe your most frustrating experience with the healthcare system related to your respiratory condition.

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Section 11 of 11

What You Wish the World Understood

This is your chance to speak directly to the people who design healthcare, build medical devices, and make policy decisions. We will carry your words into those rooms.

Q45. What do you wish your primary care doctor or pulmonologist truly understood about living with your condition?

Q46. What do you wish hospitals understood about what patients need — during a hospitalization and after they go home?

Q47. What do you wish medical device and equipment companies understood about patients' real-world needs? Think about the companies that make your inhalers, oxygen concentrators, CPAP machines, nebulizers, etc.

Q48. Is there anything else you'd like to share — something we haven't asked about that you think is important for us to understand?

Optional: Stay connected

If you'd like to be notified when Nevidra publishes research findings, shares new patient resources, or opens early access to tools, leave your email below. We will never sell your address or share it without your permission.

Section 11 of 11 — Last step!

Your Voice Shapes Better Care

About You

Your Respiratory Condition

Your Diagnosis Journey

Symptoms and Daily Challenges

Medications and Treatment

Education After Diagnosis

Quality of Life

Mental Health and Emotional Well-Being

Caregivers and Your Support Network

Your Healthcare Frustrations

What You Wish the World Understood

Thank you for sharing your story.

Your Voice Shapes Better Care

Before you begin — Your consent matters.

Antes de comenzar — Su consentimiento importa.

About You

Your Respiratory Condition

Your Diagnosis Journey

Symptoms and Daily Challenges

Medications and Treatment

Education After Diagnosis

Quality of Life

Mental Health and Emotional Well-Being

Caregivers and Your Support Network

Your Healthcare Frustrations

What You Wish the World Understood

Thank you for sharing your story.