SF Upcoming PAID study on MEDICAL CONDITIONS - May 2011

1. Medical Conditions - May 2011

Thank you for taking the time to answer these brief questions. As always, we appreciate your input as a valuable Plaza Research respondent. We have a new study on MEDICAL CONDITIONS that you maybe in interested in.

Please take note that you are ineligible to participate if you have taken part in any research study in the last 6 months.

We are looking for males and females ages 18 and up with medical conditions currently being treated by a physician. This study is a 90-minute individual interview and will take place in downtown San Francisco on Monday, May 9th or Tuesday, May 10th. The honorarium is $125.00 if you qualify and participate.

IF you qualify based on the answers provided THEN you will receive a call back. However due to the popularity of our surveys and groups, we can't contact everyone.

Please note that all responses will be returned on a first come, first served basis until the studies are full.

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* 1. Contact Information

Name

Cell Phone

Home Phone

Work Phone

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* 2. Employment Information

Job Title

Company Name

Industry

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* 3. What is your gender?

Male

Female

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* 4. Which of the following groups best fits your age?

18 or younger

19-29

30-39

40-49

50-59

60 or older

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* 5. What is your EXACT age?

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* 6. What is your current employment status?

Full-time

Part-time

Student

Homemaker

Retired

Other (please specify)

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* 7. Which of the following best describes your current living situation?

Married

Not married but living with a significant other/partner in a committed relationship

Living alone

Other (please specify)

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* 8. Which of the following best describes your ethnic background?

African-American

Asian-American

Hispanic/Latino

Caucasian

Other (please specify)

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* 9. For what conditions are you currently being treated by a physician?

Condition #1

Condition #2

Condition #3

Condition #4

Condition #5

Condition #6

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* 10. Are you, or have you even been, treated with the following drugs (check all that apply)....

Lidoderm

Qutenza

None of the above

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* 11. Are you in any way visually impaired or have any reason that you would not be able to read information and respond to visual images

Yes

**IMPORTANT: PLEASE PUSH THE "DONE" BUTTON AT THE BOTTOM OF THIS SCREEN. YOUR ANSWERS WILL NOT BE SAVED WITHOUT DOING SO!**

Thank you for participating in our survey. IF you qualify based on the answers provided THEN you will receive a call back. However due to the popularity of our surveys and groups, we can't contact everyone. Please note that all responses will be returned on a first come, first served basis until the studies are full.

*****REFERRALS ARE GREATLY APPRECIATED!*****

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* 1. Contact Information

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* 2. Employment Information

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* 3. What is your gender?

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* 4. Which of the following groups best fits your age?

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* 5. What is your EXACT age?

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* 6. What is your current employment status?

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* 7. Which of the following best describes your current living situation?

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* 8. Which of the following best describes your ethnic background?

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* 9. For what conditions are you currently being treated by a physician?

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* 10. Are you, or have you even been, treated with the following drugs (check all that apply)....

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* 11. Are you in any way visually impaired or have any reason that you would not be able to read information and respond to visual images

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* 12. ******FOR COMPANY USE ONLY****** (Please press next)

* 12. FOR COMPANY USE ONLY
(Please press next)