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MHNMWH2049 Patient Study
44.
Join our panel and start being paid for your valuable opinions.
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1.
Get Paid to Share Your Opinion!
We are conducting a Study for People who have been diagnosed with Specific Medical conditions. This project involves a Virtual Interview with a Cash Incentive upon completion for your time. Please answer the following question honestly, if you qualify you will be contacted by phone.
(Required.)
Name:
*
Company:
Address:
Address 2:
City/Town:
State:
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP:
Country:
Email Address:
*
Phone Number:
*
2.
What is your Age?
3.
Have you ever been diagnosed with any of the following health conditions by a healthcare professional?
Ankylosing Spondylitis
Crohn’s Disease
Diabetes
Gout or Gouty Arthritis
Heart disease
Kidney disease / Kidney problems
Osteoarthritis
Plaque Psoriasis
Psoriatic Arthritis
Rheumatoid Arthritis
Ulcerative Colitis
Parkinson's Disease
Epilepsy
Alzheimer’s Disease
Dementia
Schizophrenia/psychiatric-predominant disorder
Huntington’s Disease
Other neurological disease not listed
None of these
4.
Are you a CAREGIVER for someone that has been diagnosed with any of the following health conditions by a healthcare professional?
Ankylosing Spondylitis
Crohn’s Disease
Diabetes
Gout or Gouty Arthritis
Heart disease
Kidney disease / Kidney problems
Osteoarthritis
Plaque Psoriasis
Psoriatic Arthritis
Rheumatoid Arthritis
Ulcerative Colitis
Parkinson's Disease
Epilepsy
Alzheimer’s Disease
Dementia
Schizophrenia/psychiatric-predominant disorder
Huntington’s Disease
Other neurological disease not listed
None of these
5.
Please Upload a picture
Confirmation of diagnosis from your doctor — a letter, after-visit summary, or note showing your name and your diagnosis. A clear photo or screenshot is fine. 2. Picture of your pharmacy portal — a screenshot from your pharmacy’s website or app showing your name and the medication prescribed for your condition. 3. Photo of you with your medication (mirror photo) — take a picture of yourself in front of a mirror that clearly shows all three: your face, you holding the medication, and the medication label with the name readable.
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