NYC Medical Study - Adults, Parents, KIds

We're conducting a study on behalf of a major-medical firm and we would like to ask you a few questions to find out if you’d be interested in participating. The major-medical firm has developed a new syringe which could be used by people to administer medications.

We are searching for adults and children/ adolescents accompanied by their parents/ legal guardians that are interested in participating in this research.

Question Title

* 1. Contact Info

Name

Phone

E-Mail

Gender

Age

Question Title

* 2. Are you a healthcare professional?
(Someone who has received professional medical training (e.g. nurses, doctors))

Yes

Question Title

* 3. What is your....

Occupation

Industry

Question Title

* 4. Have you or a child you care for (under 18) or an adult that you care for (i.e. aging parent, etc.) ever been diagnosed with.. (SKIP IF THIS DOES NOT APPLY TO YOU)

	i have	My child has	Other Adult
Seasonal Allergies	Seasonal Allergies i have	Seasonal Allergies My child has	Seasonal Allergies Other Adult
Asthma	Asthma i have	Asthma My child has	Asthma Other Adult
Migraines	Migraines i have	Migraines My child has	Migraines Other Adult
COPD	COPD i have	COPD My child has	COPD Other Adult
Chronic Idiopathic Urticaria ( a type of hives)	Chronic Idiopathic Urticaria ( a type of hives) i have	Chronic Idiopathic Urticaria ( a type of hives) My child has	Chronic Idiopathic Urticaria ( a type of hives) Other Adult
Food Allergies	Food Allergies i have	Food Allergies My child has	Food Allergies Other Adult
Nasal Polyps	Nasal Polyps i have	Nasal Polyps My child has	Nasal Polyps Other Adult
Depression/Anxiety	Depression/Anxiety i have	Depression/Anxiety My child has	Depression/Anxiety Other Adult
ADD/ADHD	ADD/ADHD i have	ADD/ADHD My child has	ADD/ADHD Other Adult

NYC Medical Study - Adults, Parents, KIds

Question Title

* 1. Contact Info

Question Title

* 2. Are you a healthcare professional?(Someone who has received professional medical training (e.g. nurses, doctors))

Question Title

* 3. What is your....

Question Title

* 4. Have you or a child you care for (under 18) or an adult that you care for (i.e. aging parent, etc.) ever been diagnosed with.. (SKIP IF THIS DOES NOT APPLY TO YOU)

* 2. Are you a healthcare professional?
(Someone who has received professional medical training (e.g. nurses, doctors))