Lactose Intolerant Program - 2
Exit this survey
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1
. First Name
First Name
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2
. Last Name
Last Name
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3
. Street Address
Street Address
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4
. City
City
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5
. State
State
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6
. Zip Code
Zip Code
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7
. Phone Number
Phone Number
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8
. Email Address
Email Address
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9
. How old are you? (You must between 25-54 years old to participate in this program)
How old are you? (You must between 25-54 years old to participate in this program)
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10
. Sex:
Sex:
Female
Male
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11
. Are you personally affected by lactose intolerance?
Are you personally affected by lactose intolerance?
a. Yes
b. No - it is my child
c. No - it is a non-child family member
d. No - it is a friend
e. Just seeking a healthier milk alternative
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12
. Do you currently use lactose free and/or soy-type products?
Do you currently use lactose free and/or soy-type products?
a. Yes
b. No
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13
. How many cups of lactose free milk do you consume per day?
How many cups of lactose free milk do you consume per day?
a. 0
b. 1-3
c. 3+
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14
. Are you interested in experiencing a new lactose free milk?
Are you interested in experiencing a new lactose free milk?
a. Yes
b. No
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15
. How does lactose intolerance impact your daily food choices: breakfast, lunch and dinner?
How does lactose intolerance impact your daily food choices: breakfast, lunch and dinner?
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16
. How many friends/co-workers would you say you communicate with regarding lactose intolerance or lactose free food options on a weekly basis?
How many friends/co-workers would you say you communicate with regarding lactose intolerance or lactose free food options on a weekly basis?
a. 0
b. 1-5
c. 5-10
d. 10-20
e. 20+
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17
. If you were introduced to a new product that decreases the symptoms of lactose intolerance and liked it, would you be willing to share it with others?
If you were introduced to a new product that decreases the symptoms of lactose intolerance and liked it, would you be willing to share it with others?
a. Yes
b. No
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18
. How do you look for information about lactose intolerance? (please check all that apply)
How do you look for information about lactose intolerance? (please check all that apply)
a. Blogs
b. Websites
c. Receive e-newsletters via email
d. Magazines
e. In-person support groups
f. Online support groups i.e Yahoo! Group, Facebook or other chat groups
Other (please specify)
19
. If you checked any of the above, please list the individual locations, such as "Health Magazine."
If you checked any of the above, please list the individual locations, such as "Health Magazine."
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20
. Do you actively engage in lactose intolerant conversations on social media networks/tools such as a blog, Facebook page, newsletter, magazine etc. If so, please share it with us.
Do you actively engage in lactose intolerant conversations on social media networks/tools such as a blog, Facebook page, newsletter, magazine etc. If so, please share it with us.
a. Yes
b. No
21
. If you checked "yes", please list the names/urls:
If you checked "yes", please list the names/urls:
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