Exit this survey MEDICAL CONDITIONS NATIONAL 1. Question Title 1. Please complete the contact information below. First and Last Name: * Company: Address: * Address 2: 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. What is your gender? Male Female Question Title 3. Which of the following age categories best describes your age? Under 18 years old 18 – 29 years old 30 – 44 years old 45 – 59 years old 60 – 69 70 or older Question Title 4. Do you have any of the following conditions? Ankylosing Spondylitis Plaque Psoriasis Psoriatic Arthritis Rheumatoid Arthritis (RA) Cystic Fibrosis Pancreatic Cancer EPI (exocrine pancreatic insufficiency) Hidradentitis Suppurativa (HS) HIV Hepatitis C Ulcerative Colitis Crohn's Disease (CD) Breast cancer-Stage I Breast cancer-Stage II Breast cancer-Stage III Breast cancer-Stage IV Non-Hodgkins Lymphoma Kidney Diesease ( such as MPGN, FSGS, Lupus, Bergers Disease , IGA Neuropathy, IMN ) Autism Asperger’s syndrome Down’s syndrome Duchenne muscular dystrophy Leukemia None of the above Other (please specify) Question Title 5. Do you currently take a prescription medication for daily use? Yes No Question Title 6. What type of health insurance, if any, [are you/is your child] covered by? Health insurance that is provided by an employer Health insurance you purchase directly Medicare Medicaid Military coverage (such as TRI CARE or a VA program) Health insurance provided by the state in which you live Other/None Question Title 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? A drug store or pharmacy… A pharmaceutical company or healthcare manufacturer… A marketing or market research department or company … An advertising agency… A journalism or public relations agency… A government regulatory agency… As a clinical investigator conducting clinical trials or providing consulting services for a drug to treat inflammatory bowel disease … Kaiser Permanente… An HMO or health insurance company… None of the above… Question Title 8. Approximately which best describes your highest attained education level? Did not receive high school diploma High school diploma Associate’s degree Bachelor’s degree Master’s degree PhD or Professional degree Prefer not to say Question Title 9. What is your ethnicity? Caucasian African American / Black Asian American Indian / Native American Hispanic / Latino Other (please specify) Question Title 10. Into which of the following bands does your annual household income fall? Under $50,000 $50,000-$59,999 $60,000-$69,999 $70,000-$79,999 $80,000-$89,999 $90,000-$100,000 Over $100,000 Don’t Know/Refused Question Title 11. What is your current work status? Full-Time Employed Part-Time Employed Homemaker Unemployed / Looking for work Retired Student Full-Time Question Title 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) Occupation: Company: Industry: Question Title 13. 9. What is your current marital status? Single - Never Married Single - Divorced Single - Widowed Single - Separated Live with Partner / Co-Hab Married Next
