Alpha-1 Screener

Click the boxes below that match your symptoms. Then print out this sheet and take with you when you next see your doctor.

I currently have, or have recently had, these symptoms: (click all that apply)

Shortness of breath with normal activity

Shortness of breath at rest

Wheezing

Frequent cough with or without mucus

I have been diagnosed with: (click all that apply)

COPD – emphysema, chronic bronchitis or bronchiectasis

Emphysema without being a smoker

Asthma that is not controlled with rescue medication

Liver disease

Necrotizing panniculitis (looks like raised red spots on the skin)

I have a family history of: (click all that apply)

COPD – emphysema, chronic bronchitis, or bronchiectasis

Asthma

Liver disease

Unexplained death of a family member

Please talk to your doctor about your symptoms. Find out if a test for Alpha-1 is right for you.

Print these results to take with you when you see your doctor.