Houston Study - Health Conditions March 2017

1. Introduction Section

Plaza Research Houston is conducting a discussion with 50-64 year old MALES who are insured (other than and HMO) regarding Health Conditions. The discussion will take place on Thursday, March 9, 2017, in the late afternoon and evening. If you qualify and participate, you will $100 for 2.25-hours of your time.

Please answer the questions below. If you look like a match, we will contact you by telephone.

**Due to the large response to our surveys, we are only able to contact those that look like a match. Please continue to answer future studies, as you may be a match to those.

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* 1. Please provide us with the following information. We will be contacting you by telephone if you seem like a match.

Name:

ZIP/Postal Code:

Email Address:

Phone Number:

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* 2. Alternate Contact number

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* 3. What is your age? Whole number, no ranges or words

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* 4. What is your gender?

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* 5. What year were you born?

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* 6. Do you currently receive medical care from the VA or Veterans Administration?

Yes