SurveyMonkey Powered Online Survey

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* 1. This survey is being conducted by Adler Weiner Research in order to determine your eligibility for a focus group or interview about which you have been contacted. At no point are your individual answers ever sold or shared with our clients (aggregate data or anonymized summaries of the overall survey information may possibly be shared with our clients, however). This survey serves solely as a means for screening. Once the project has been completed this data will be deleted. For more information please see:
Right to Opt-Out Info
Financial Incentive Info
Adler Weiner Privacy Policy

I consent to Adler Weiner Research collecting, storing and processing my personal information for the purpose of determining my eligibility for this market research focus group or interview.

I understand and consent to the following: That should I be eligible for participation in this market research focus group or interview, my contact information (phone, email, and home address) may be shared with the client for purposes related only to this particular project and are not limited to: screening calls to further determine eligibility, sending of "homework" or pre-session assignments via email, allowing access to an online platform via email, or for in-home interviews conducted at your residence.

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* 2. CONTACT INFO Please provide the following:

Name *

Address *

Apt # if applicable

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

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* 3. Gender:

Male

Female

Non-Binary/Other

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* 4. 1) What is your age?

Under 18

18-24

25-34

35-44

45-54

55-64

65+

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* 5. Are you able to read, write, and understand English?

Yes

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* 6. What is the highest level of education you have completed?

 High School Diploma / GED

 Associate’s Degree / Some College

 Bachelor / College

 Advanced Degree

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* 7. Are you, or is any member of your immediate family currently an employee, a paid consultant to, or associated with a pharmaceutical / biotech company, medical device manufacturer, a healthcare company, a market research firm or an advertising agency?

Yes

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* 8. Are you a physician, nurse, pharmacist or other healthcare professional?

Yes

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* 9. What health conditions have you been diagnosed with by a healthcare provider?

 Pulmonary Arterial Hypertension (PAH)

 Pulmonary Hypertension associated w/ Interstitial Lung Disease (PH-ILD)

 Interstitial Lung Disease (ILD)

 Idiopathic Pulmonary Fibrosis (IPF)

 Hypersensitivity Pneumonitis

 Idiopathic Interstitial Pneumonia (IIP)

 Idiopathic Nonspecific Interstitial Pneumonia

 Respiratory Bronchiolitis-Associated w/Interstitial Lung Disease (RB-IID)

 Desquamative Interstitial Pneumonia (DIP)

 Cryptogenic Organizing Pneumonia (COP)

 Acute Interstitial Pneumonia (AIP)

 Idiopathic Lymphoid Interstitial Pneumonia

 Idiopathic Pleuroparenchymal Fibroelastosis

 Unclassified Idiopathic Interstitial Pneumonia

 Combined Pulmonary Fibrosis and Emphysema (CPFE)

 Asbestosis

 Pulmonary Hypertension (PH)

 Chronic Obstructive Pulmonary Disease (COPD)

 Congestive Heart Failure (CHF)

 Pulmonary Fibrosis

 Attention Deficit Hyperactivity Disorder (ADHD)

 Obsessive Compulsive Disorder (OCD)

Diabetes (Type 1 or 2)

Multiple Sclerosis (MS)

Crohn's

Gastroesophageal Reflux Disease (GERD)

Celiac Disease

Other (please specify)