Survey

This is a 2 part online Survey . We need to ask a few questions before we know if you are eligible for an upcoming group. Please answer the questions below and if we can use you, you will received a part 2 with additional questions.

1. Name (First & Last)

Name (First & Last)

2. Gender

Gender Male

Female

3. Work Phone Number

Work Phone Number

4. Cell Phone Number

Cell Phone Number

5. Best contact number between the hours of 9am-7pm

Best contact number between the hours of 9am-7pm

6. Age

Age

7. Email Address

Email Address

8. Race

Race White or Caucasian

Hispanic or Latino

Black or African-American

Asian-American or Pacific Islander

Native American or American Indian

Other (please specify)

9. Are you currently a member of our database or was this email forwarded to you by someone else?

Are you currently a member of our database or was this email forwarded to you by someone else? Current member

Email forwarded

Don’t know

10. When was the last time you participated in a research focus group or one on one interview?

When was the last time you participated in a research focus group or one on one interview? Less than 3 months ago

3-6 months ago

6-12 months ago

More than 1 year ago

Never

11. Does anyone in your immediate family or any of your close friends work in marketing research or advertising?

Does anyone in your immediate family or any of your close friends work in marketing research or advertising? Yes

12. Does anyone in your immediate family or any of your close friends work as a medical professional, such as a doctor, nurse, or pharmacist?

Does anyone in your immediate family or any of your close friends work as a medical professional, such as a doctor, nurse, or pharmacist? Yes

13. Does anyone in your immediate family or any of your close friends work for a pharmaceutical company?

Does anyone in your immediate family or any of your close friends work for a pharmaceutical company? Yes

14. Have you ever been diagnosed by a doctor with any of the following medical conditions…

	Yes	No
Lupus	Have you ever been diagnosed by a doctor with any of the following medical conditions… Lupus Yes	No
High Blood pressure	High Blood pressure Yes	No
High Cholesterol	High Cholesterol Yes	No
Diabetes	Diabetes Yes	No
HIV/AIDS	HIV/AIDS Yes	No
Depression or anxiety	Depression or anxiety Yes	No
Raynaud’s Disease	Raynaud’s Disease Yes	No
Sleeping problems	Sleeping problems Yes	No
Crohn’s Disease	Crohn’s Disease Yes	No
Kidney disease	Kidney disease Yes	No

1. Health Issues