SF Upcoming PAID study on Men's Heart Disease- January 19, 2011

1. SF Upcoming PAID study on Men's Heart Disease- January 19, 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 Men's Heart Disease that you may be 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 who have some form of heart disease. This study is a 90-minute focus group discussion during the afternoon or evening and will take place in downtown San Francisco on Wednesday, January 19. 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?

Under 55

55-64

65-74

75 or older

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* 5. What is your EXACT age?

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* 6. Which of the following medical conditions, if any, have you ever had?

Heart Attack

Sudden Cardiac Arrest

Coronary Artery Bypass Surgery

Cardiac Stent

Blocked Arteries

Congestive Heart Failure

None of these

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* 7. IF you have had congestive heart failure, how would you describe your symptoms of congestive heart failure?

Mild

Moderate

Severe

Not applicable

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* 8. Which, if any, of the following cardiac devices do you currently have implanted?

Pacemaker

Pacemaker/defibrillator

Defibrillator or ICD (Implantable Cardioverter Defibrillator)

CRT-D (Cardiac Resynchronization Therapy) or Bi-Ventricular Device/Bi-V Device

None of these

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* 9. How comfortable would you say you are in sharing your thoughts and opinions in a group discussion? Would you say that you are:

Extremely comfortable

Very comfortable

Somewhat comfortable

Not very comfortable

Not at all comfortable

**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. Which of the following medical conditions, if any, have you ever had?

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* 7. IF you have had congestive heart failure, how would you describe your symptoms of congestive heart failure?

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* 8. Which, if any, of the following cardiac devices do you currently have implanted?

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* 9. How comfortable would you say you are in sharing your thoughts and opinions in a group discussion? Would you say that you are:

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* 10. FOR COMPANY USE ONLY
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