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Part I

1.Gender:

2.Age:

3.Height:
If you do not know your height in feet, please enter it in meters below:


4.Weight (lbs.):
If you do not know your weight in pounds, please enter it in kilograms below:


5.Country:

6.Race:

Part II

7.How many pneumothoraces (pneumothorax) have you been treated for?

8.How many times has your right lung collapsed?

9.How many times has your left lung collapsed?

10.What type of detection and tests have been utilized in identifying your pneumothorax?
(Check all that apply)
None
Arterial Blood Gases
CT Scan
X-Ray


11.What type(s) of treatment have you received?
(Check all that apply)
Chest Tube Insertion
Medical Observation Only
Surgical Intervention
Chemical Treatment (e.g Talc)
Other


12.Did you have a pneumothorax on the same lung after you received treatment? Yes
No


13.How old were you when you had your first pneumothorax?

14.How old were you when you had your most recent pneumothorax?

15.What type(s) of pneumothorax have you had?
(Check all that apply)
Catanemial
Spontaneous
Tension
Traumatic


16.Did you know what a pneumothorax was before you had one? Yes
No


17.Have any of your family members or relatives been treated for a pneumothorax?
(Check all that apply)
No
Father
Mother
Brother
Sister
Son
Daughter
Other Relative


18.Do you, or have you had a cigarette smoking habit? Yes
No


19.How would you classify yourself as a smoker?

20.While you were growing up, to what degree were you exposed to second-hand smoke?

21.Presently, to what degree are you exposed to second-hand smoke?

22.Do you believe you will have another pneumothorax? Yes
No

Part III (Optional)

23.Please describe your pneumothorax experience in detail:




24.Can we post your experience in our pneumothorax.org personal experiences area? No
Yes


25.Please enter your e-mail address if you would like to participate in future pneumothorax research?


Please click submit below to submit your survey. Thank you.