* 1. What is your first name?

* 2. What is your last name?

* 3. What's your email address?

* 4. How old are you?

* 5. In what city/state do you live? For example: Queens, NY

* 6. Do you have any of the following chronic health conditions?

* 7. How old were you when first diagnosed?

* 8. How did you hear about this study?

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