*1.Please fill out the information below. (Required.)

Name:

City/Town:

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:

*2.What is your current age?(Required.)

*3.What is your gender?(Required.)

*4.What is your household annual income?(Required.)

*5.What is your current employment status?(Required.)

*6.What is your highest level of education?(Required.)

*7.What is your ethnicity?(Required.)

*8.When it comes to decisions about your household's pharmaceutical and health care purchases, what role do you play?(Required.)

I am primary decision maker

I share

I have some imput

I am not involved

*9.Please indicate which specific brand(s) of footcare products you have used in the last 12 month? If none, then just select none. (Required.)

Aetrex

Airplus

Compound W

Dr Scholl's

Foot Petals

Gold Blond

Odor Eaters

Pro Foot

Spenco

Store Brands

None of the above

*10.Please answer yes or no to the following questions. (Required.)

Yes

No

Keeping your balance when you walk

Yes

No

Do you use a cane

Yes

No

Have you fallen due to balance issues

Yes

No

Do you tend to lean on things to maintain your balance

Yes

No

*11.Have you ever had any of the following procedures?(Required.)

Appendectomy

Knee replacement

Hip replacement

Hernia repair

None of the above