Tell us your Bronchiectasis Adult story
Have you been diagnosed with Bronchiectasis Adult? (Optional)
Select One
Yes
No
Not Sure
Not Applicable
Does Bronchiectasis Adult impact relationships with family or caregivers? (Optional)
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Yes
Somewhat
No
Not Sure
Not Applicable
Does Bronchiectasis Adult impact your daily exercise or other activities? (Optional)
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Yes
Somewhat
No
Not Sure
Not Applicable
Does Bronchiectasis Adult impact your mental health? (Optional)
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Yes
Somewhat
No
Not Sure
Not Applicable
Does Bronchiectasis Adult impact your healthcare costs? (Optional)
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Yes
Somewhat
No
Not Sure
Not Applicable
Are you currently looking for a Bronchiectasis Adult clinical trial? (Optional)
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Yes
No
Not Sure
Not Applicable
First Name
Last Name
Email
Phone (Optional)
Age (Optional)
Postal Code (Optional)
Gender (Optional)
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Male
Female
Transgender Male
Transgender Female
Gender Variant/Non-Conforming
Unspecified
How would you like to be contacted? (Optional)
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Phone Call
SMS
Text
Any
What would you like researchers to know about your experience with Bronchiectasis Adult? (Optional)
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