MEDICAL CONDITIONS

MURRAY HILL PRIVACY STATEMENT/POLICY

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Question Title

1. Murray Hill national is conducting a study.

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

Question Title

2. What is your age?

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3. What is your gender?

Male

Female

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4. Which categories describe you? You may select more than one group.

Hispanic, Latino, or Spanish

Native American, First Nations

Alaska Native

Central or South American Indigenous

Asian, Asian American, or Pacific Islander

Black, African American, or Caribbean

Middle Eastern or North African

Native Hawaiian

White / Caucasian

Question Title

5. Which of the following best describes how you pay for your or your household's prescription medications?

Commercial insurance (employer-sponsored or individual-managed care/private/HMO/PPO/HSA/FSA)

Medicare

Medicaid

Entirely out-of-pocket / cash

No insurance

Decline to answer / don't know

Question Title

6. Have you ever been diagnosed by a healthcare professional with any of the following conditions?

Type 1 Diabetes

Type 2 Diabetes (also known as adult-onset diabetes)

Pre-diabetes/insulin resistant/high blood sugar but not diagnosed with diabetes

Unstable Angina

Stroke/TIA (transient ischemic attack or "mini stroke")

Acute Coronary Syndrome (ACS)

Peripheral Artery Disease (PAD)

Arterial Blockage (i.e., one or more blocked arteries, anywhere in the body, with or without a stent)

Atrial Fibrillation

Heart failure/CHF

High blood pressure or hypertension

High cholesterol

HFpEF (heart failure with preserved ejection fraction)

Fatty Liver Disease or MASH/NASH

Chronic or "long-term" kidney disease

Osteoarthritis (OA)

Psoriatic arthritis

Chronic pain

Chronic fatigue

Rheumatoid arthritis

Gout

Hepatitis

Polycystic Ovary Syndrome (PCOS)

Cancer

Thyroid disease (e.g., hypothyroidism, Hashimoto's thyroiditis, Grave's)

Obstructive Sleep Apnea (OSA)

Pancreatitis

Anxiety/Depression

Asthma/shortness of breath/wheezing

Memory/thinking disorders

Stress urinary incontinence (e.g., urine leak with cough, sneeze, laughing, movement, or activity)

Gallbladder disease

None of the above

Question Title

7. When were you first diagnosed with Type 2 Diabetes?

Within the last 6 months

6-12 months ago

1 to less than 3 years ago

3 to 5 years ago

6 to 10 years ago

11 to 15 years ago

16 to 20 years ago

More than 20 years ago

Question Title

8. What is your current A1c level?

Less than 6.9

7.0 – 7.4

7.5 – 8.0

8.1 – 8.4

8.5 – 9.0

9.1+

Not sure

Question Title

9. Thinking about your most recent visits with your doctor about your Type 2 diabetes, which one of the following statements is most accurate?

My doctor and I have discussed that my A1c is not where it should be

My doctor says my A1c is good/in-control

My doctor and I have not discussed my A1c

Question Title

10. Which of the following best describes how you are currently managing your Type 2 diabetes?

Diet and exercise

Orals for Type 2 diabetes (pills)

An injectable therapy that is not insulin

Basal or long-acting insulin (likely one injection per day)

Bolus, mealtime, or fast-acting insulin (insulin injections you take with your meals)

None of the above

Question Title

11. How much do you agree or disagree with the following statements?

	Disagree Completely	Disagree Somewhat	Agree Somewhat	Agree Completely
My Latino cultural/ethnic heritage is an important part of who I am.	My Latino cultural/ethnic heritage is an important part of who I am. Disagree Completely	My Latino cultural/ethnic heritage is an important part of who I am. Disagree Somewhat	My Latino cultural/ethnic heritage is an important part of who I am. Agree Somewhat	My Latino cultural/ethnic heritage is an important part of who I am. Agree Completely	My Latino cultural/ethnic heritage is an important part of who I am.
Being part of American culture is important to me.	Being part of American culture is important to me. Disagree Completely	Being part of American culture is important to me. Disagree Somewhat	Being part of American culture is important to me. Agree Somewhat	Being part of American culture is important to me. Agree Completely	Being part of American culture is important to me.
I'd like to feel more "American" and closer to American culture.	I'd like to feel more "American" and closer to American culture. Disagree Completely	I'd like to feel more "American" and closer to American culture. Disagree Somewhat	I'd like to feel more "American" and closer to American culture. Agree Somewhat	I'd like to feel more "American" and closer to American culture. Agree Completely	I'd like to feel more "American" and closer to American culture.
I consider myself more "American" than "Hispanic or Latino."	I consider myself more "American" than "Hispanic or Latino." Disagree Completely	I consider myself more "American" than "Hispanic or Latino." Disagree Somewhat	I consider myself more "American" than "Hispanic or Latino." Agree Somewhat	I consider myself more "American" than "Hispanic or Latino." Agree Completely	I consider myself more "American" than "Hispanic or Latino."

MEDICAL CONDITIONS

MURRAY HILL PRIVACY STATEMENT/POLICY

Question Title

* 1. Murray Hill national is conducting a study.

Question Title

* 2. What is your age?

Question Title

* 3. What is your gender?

Question Title

* 4. Which categories describe you? You may select more than one group.

Question Title

* 5. Which of the following best describes how you pay for your or your household's prescription medications?

Question Title

* 6. Have you ever been diagnosed by a healthcare professional with any of the following conditions?

Question Title

* 7. When were you first diagnosed with Type 2 Diabetes?

Question Title

* 8. What is your current A1c level?

Question Title

* 9. Thinking about your most recent visits with your doctor about your Type 2 diabetes, which one of the following statements is most accurate?

Question Title

* 10. Which of the following best describes how you are currently managing your Type 2 diabetes?

Question Title

* 11. How much do you agree or disagree with the following statements?

1. Murray Hill national is conducting a study.

2. What is your age?

3. What is your gender?

4. Which categories describe you? You may select more than one group.

5. Which of the following best describes how you pay for your or your household's prescription medications?

6. Have you ever been diagnosed by a healthcare professional with any of the following conditions?

7. When were you first diagnosed with Type 2 Diabetes?

8. What is your current A1c level?

9. Thinking about your most recent visits with your doctor about your Type 2 diabetes, which one of the following statements is most accurate?

10. Which of the following best describes how you are currently managing your Type 2 diabetes?

11. How much do you agree or disagree with the following statements?