1.

Please complete the contact information below.

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1. Please complete the contact information below.

What is your gender?

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2. What is your gender?

Which of the following age categories best describes your age?

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3. Which of the following age categories best describes your age?

Do you have any of the following conditions?

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4. Do you have any of the following conditions?

Do you currently take a prescription medication for daily use?

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5. Do you currently take a prescription medication for daily use?

What type of health insurance, if any, [are you/is your child] covered by?

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6. What type of health insurance, if any, [are you/is your child] covered by?

Are you, or is an immediate family member, currently or within the past 6 months employed by or under contract with any of the following?

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7. Are you, or is an immediate family member, currently or within the past 6 months employed by or under contract with any of the following?

Approximately which best describes your highest attained education level?

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8. Approximately which best describes your highest attained education level?

What is your ethnicity?

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9. What is your ethnicity?

Into which of the following bands does your annual household income fall?

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10. Into which of the following bands does your annual household income fall?

What is your current work status?

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11. What is your current work status?

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)

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12. 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)

9. What is your current marital status?

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13. 9. What is your current marital status?

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