Osteoarthritis 1. Question Title 1. Please complete the contact information below. First and Last Name: Address: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Email Address: Phone Number: Question Title 2. First, do you, or anyone in your immediate family, work in the Advertising / Marketing / Market Research industry? Yes No Question Title 3. Do you have access to a computer, which is connected to the internet for the interview? Yes No Question Title 4. Which of the following age groups do you belong to? A. Less than 18 years old B. 18 to 30 years old C. 31 to 40 years old D. 41 to 50 years old E. 51 to 60 years old F. 61 years old or older Question Title 5. Have you personally been diagnosed by a doctor as having Osteoarthritis / OA? Yes No Question Title 6. How, if at all, are you currently being treated for your OA? A. I take prescription medication for my condition B. I take over-the-counter medicines (medicines I don’t need a doctor’s prescription for) C. I use non-drug or alternative therapies to treat my condition (e.g. physiotherapy, occupational ) D. I don’t receive any treatment or therapy for my condition Other (please specify) Question Title 7. What is the name of the prescription/OTC medication(s) that you are currently taking for your OA? A. Celebrex B. Duexis C. Prescription Generic Ibuprofen D. OTC Advil or Motrin E. OTC Aleve Other (please specify) Question Title 8. Do you have health insurance? If yes, who is your provider / what type of insurance do you have? A. Commercial Insurance B. Medicare or Medicaid Question Title 9. Can you tell us about any risks and/or side effects that you are aware of / heard of / read about or are concerned with when treating your OA? Question Title 10. What is your gender? Female Male Question Title 11. What is the highest level of education you have completed? Attended high school or less High school graduate or equivalant Attended community college Graduate with two-year degree Attended university Graduate with bachelor’s degree Attended/Have Postgraduate degree Question Title 12. What is your marital status? : Married Single Other (please specify) Question Title 13. What is your total annual household income? LESS THAN $30,000 $30,000- $44,999 $45,000 - $54,999 $55,000 - $74,999 $75,000 - $100,000 $100,000+ Prefer not to answer Question Title 14. What is your ethnicity? Caucasian African American / Black Asian American Indian / Native American Hispanic / Latino Other (please specify) Question Title 15. What is your Occupation-Job Title, Company you work for, and Industry? (If you are Retired, Unemployed or a Homemaker Please tell us your previous employment information. If you are a full-time student please enter your Grade, School and Major) Occupation: Company: Industry: Next
