Primary Billary Cirrhosis (PBC) "Qualifying Questionnaire"

We are a branch of a larger market research company, whose goal is to make contact with as many people diagnosed with Primary Billary Cirrhosis (PBC). We will be looking to reach out to those who show interest in the form of online surveys and telephone discussions to understand the needs of PBC patients. When contacted and qualified we will pay respondents for their time (up to $100).

All information collected during the surveys or phone discussions are completely confidential in that your name or other identifying information will not be shown to our clients.

Question Title

* 1. Please indicate age when diagnosed.

<39 years

40 - 49 years

50 - 59 years

60> years

Question Title

* 2. Please note treatments utilized, if any, for diagnosed PBC

Cyclosporine

Colchicine

Ursodiol (Actigall™, Ursosan™, Ursofalk™, BILIVER™, Egyurso™, Urso™, Urso Forte™, Deursil™ and Coric™)

Drug Trial - Note in "Other" specifics

Other (please specify)

Question Title

* 3. Please provide basic demographic information.

Name, Phone number and ZIP are requested not required at this time.

Name:

City/Town:

State:

ZIP:

Email Address: *

Phone Number:

Thank you very much for taking the time to fill out this short questionnaire. We are collecting basic information to match individuals with specific survey requirements in order to invite your participation.

Question Title

* 1. Please indicate age when diagnosed.

Question Title

* 2. Please note treatments utilized, if any, for diagnosed PBC

Question Title

* 3. Please provide basic demographic information.Name, Phone number and ZIP are requested not required at this time.

* 3. Please provide basic demographic information.

Name, Phone number and ZIP are requested not required at this time.