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F. Biomedicale,

. Titre-de-la-recherche, Prévalence de la sarcopénie chez des patients obstructifs chroniques hospitalisés en Pneumologie au CHU de Clermont-Ferrand Je soussigné(e) ??????????????????????

, Accepte de participer à l'étude « Prévalence de la sarcopénie chez des patients obstructifs chroniques hospitalisés en Pneumologie

, Les objectifs et modalités de l'étude m'ont été clairement expliqués par l'interne Mr Loïc PERROT

, et compris la fiche d'information qui m'a été remise

, J'accepte que les documents de mon dossier médical qui se rapportent à l'étude puissent être accessibles aux responsables de l'étude et éventuellement aux autorités de santé. A l'exception de ces personnes, qui traiteront les informations dans le plus strict respect du secret médical, mon anonymat sera préservé

, Je pourrai exercer mon droit d'accès et de rectification auprès du Dr Annick GREIL, ou de son interne Loïc PERROT

, J'ai bien compris que ma participation à l'étude est volontaire

, Je suis libre d'accepter ou de refuser de participer, et je suis libre d'arrêter à tout moment ma participation en cours d'étude. Cela n'influencera pas la qualité des soins qui me seront prodigués

, Mon consentement ne décharge pas les organisateurs de cette étude de leurs responsabilités. Je conserve tous mes droits garantis par la loi

, Après en avoir discuté et avoir obtenu la réponse à toutes mes questions, j'accepte librement et volontairement de participer à la recherche qui m'est proposée

, Le ??????????????? physical activity (circle your situation):-Never-Regular (more than 30 minutes a day

, Evaluate Your Smoking: Please complete this questionnaire

. , About your tobacco use (circle your situation): Never Stopped since

. , If you smoked, how many years?

. , If you smoked, how many cigarettes per day (average)?

, NB: A patient who has "never" smoked is considered to have consumed less than 100 cigarettes throughout his / her lifetime, p.58