Wine Study #1229

First Name

Last Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Male

Female

Non-binary

Other (please specify)

Education

Medicine

Law Enforcement

Marketing or advertising

Market research

Hospitality and/or food and beverage

None of the above

Urban

Suburban

Rural/Small town

Yes

	Never	Less than once a week	About once a week	About twice a week	3-5 times per week	More than 5 times per work
Coffee	Coffee Never	Coffee Less than once a week	Coffee About once a week	Coffee About twice a week	Coffee 3-5 times per week	Coffee More than 5 times per work
Soda/Pop	Soda/Pop Never	Soda/Pop Less than once a week	Soda/Pop About once a week	Soda/Pop About twice a week	Soda/Pop 3-5 times per week	Soda/Pop More than 5 times per work
Beer	Beer Never	Beer Less than once a week	Beer About once a week	Beer About twice a week	Beer 3-5 times per week	Beer More than 5 times per work
Wine	Wine Never	Wine Less than once a week	Wine About once a week	Wine About twice a week	Wine 3-5 times per week	Wine More than 5 times per work

I am primarily/solely responsible

I share equal responsibility with another person in my home

Someone else is primarily responsible for buying wine at home