Impact of Living with a Chronic Cough

1. What is the current status of your cough?
  *This question is required.

• I am no longer living with a cough.
• The cause of my cough has been diagnosed but my cough has NOT improved.
• The cause of my cough has NOT been diagnosed and I am still coughing.
• My cough has gotten better but I am still coughing.

2. Has a healthcare provider ever told you that you have one or more of following types of cough? (check all that apply) *This question is required.

• Chronic cough
• Persistent chronic cough
• Refractory chronic cough
• Unexplained chronic cough
• Neurogenic cough (cough stemming from the nervous system)
• Tic or habit cough
• Cough hypersensitivity syndrome
• Psychogenic cough (cough stemming from stress or anxiety)
• None of the above
• Other - Write In Please enter an 'other' value for this selection.

2. How long did it take for you to get the cause of your cough diagnosed?
  *This question is required.

• One year or less
• Two to three years
• Four to five years
• Over six years
• The cause of my cough has NOT been diagnosed.

2. Since your cough started, select the different type of specialties you have visited to discuss your chronic cough. (check all that apply) *This question is required.

• Pulmonology (lungs)
• Allergy
• Gastroenterology (stomach)
• Primary care
• Ear, nose and throat
• Cardiology (heart)
• Neurology (nervous system)
• Speech therapy
• Other - Write In Please enter an 'other' value for this selection.

2. Has your healthcare provider ever told you that your chronic cough is caused by any of the following health conditions? (check all that apply) *This question is required.

• Lung condition like asthma
• Heart burn, reflux or GERD (gastroesophageal reflux disease)
• Sinus or nasal issues
• Heart condition
• Anxiety or stress
• No health conditions
• Other - Write In Please enter an 'other' value for this selection.

2. How are you currently treating or managing your chronic cough? (check all that apply) *This question is required.

• Medications prescribed by my healthcare provider
• Over the counter cough medications such as cough drops
• I am not taking medications or being treated for my cough
• Removing or reducing triggers such as strong smells or chemicals
• Seeing a speech or behavioral specialist
• Other - Write In Please enter an 'other' value for this selection.

2. In the past year, what were the barriers to accessing care for your chronic cough? (check all that apply)
  *This question is required.

• I am no longer seeking medical treatment for my cough
• Wait time to see specialists and doctors
• Lack of insurance coverage for medical appointments, medications, tests and procedures
• Scheduling medical appointments interfere with work or other responsibilities
• Lack of communication between the different providers I see for my cough
• Lack of concern about my cough from healthcare providers
• Other - Write In Please enter an 'other' value for this selection.

2. About how many times do you cough per day? Include the number of coughs during each episode or spasm. *This question is required.

• Less than 100 times per day
• 101-400 times per day
• 401-700 times per day
• more than 701 times per day

2. Within the past 2 weeks, because of your chronic cough, how would you rate your quality of life? *This question is required.

• Very poor
• Poor
• Neither good nor bad
• Good
• Very good

2. In the past two weeks, how has your chronic cough impacted your quality of life? Because of my cough, I am..... (check all that apply)
  *This question is required.

• Staying awake throughout the night.
• Sleepy during the day because my cough interrupts my sleep.
• Having physical symptoms such as bladder leakage, vomiting and/or chest pain.
• Having trouble completing daily activities such as cleaning or shopping.
• Less productive at work.
• Other - Write In Please enter an 'other' value for this selection.

2. Within the past 2 weeks, because of your chronic cough, how would you rate your social life? *This question is required.

• Very poor
• Poor
• Neither good nor bad
• Good
• Very good

2. In the past two weeks, how has your chronic cough impacted your social life? Because of my cough, I am....  (check all that apply)
  *This question is required.

• Limiting or avoiding talking on the phone with friends and family.
• Limiting or avoiding activities I enjoy or hobbies.
• Limiting or avoiding going out and socializing in public with others.
• Having to explain to others about my cough so they do not think I am sick.
• Other - Write In Please enter an 'other' value for this selection.

2. Within the past 2 weeks, because of your chronic cough, how would you rate your emotional or mental health? *This question is required.

• Very poor
• Poor
• Neither good nor bad
• Good
• Very good

2. In the past two weeks, in what ways has living with a chronic cough impacted your emotional or mental health? Because of my cough, I feel....  (check all that apply)  *This question is required.

• Anger
• Worry
• Scared
• Depressed
• Happy
• Calm
• Sad
• Frustration
• Fear
• Anxious
• Embarrassed
• Disgust
• Surprise
• Shame
• Stress
• Other - Write In Please enter an 'other' value for this selection.

2. What is your tobacco use history?

  *This question is required.

• I currently use tobacco products.
• I have used tobacco products in the past.
• I have never used tobacco products.

2. Would you like to receive a copy of the final report? 

• Yes
• No