Exit this survey Diagnosed Health Conditions 1. Question Title 1. Please complete the contact information below. First and Last Name: Address: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Email Address: Phone Number: Question Title 2. Please supply us with a secondary contact number. Murray Hill Center standard policy requires at least two contact numbers for each respondent. If the secondary number you give us is not your own number but a friend, family member or co-worker please indicate as such. Question Title 3. Have you ever participated in or are you currently participating in any clinical trial(s)? Yes No Question Title 4. What is your gender? Male Female Question Title 5. What is your current age? Question Title 6. What type of health insurance, if any, do you have? Medicaid (MediCal for California residents) Medicare only Medicare HMO/Advantage or supplemental plan Health insurance provided through work or union Purchased health insurance coverage through an exchange or state risk pool Purchased individual coverage Veterans Administration (VA) CHAMPUS/Active Military/Tri-care, etc. Other type of health insurance (please specify) Not sure No health insurance Question Title 7. Are you of Hispanic origin, such as Latin American, Mexican, Puerto Rican, or Cuban? Yes, of Hispanic origin No, not of Hispanic origin Prefer not to state Question Title 8. What is your ethnicity? Caucasian African American / Black Asian American Indian / Native American Hispanic / Latino Other (please specify) Question Title 9. Which of the following categories includes your total annual household income from 2013 before taxes? Under $10,000 $10,000 - $14,999 $15,000 - $19,999 $20,000 - $24,999 $25,000 - $29,999 $30,000 - $34,999 $35,000 - $39,999 $40,000 - $44,999 $45,000 - $49,999 $50,000 - $54,999 $55,000 - $59,999 $60,000 - $64,999 $65,000 - $69,999 $70,000 - $74,999 $75,000 - $79,999 $80,000 - $89,000 $90,000 - $99,999 $100,000 - $109,999 $110,000 - $119,999 $120,000 or more Prefer not to state Question Title 10. What is your current work status? Full-Time Employed Part-Time Employed Homemaker Unemployed / Looking for work Retired Student Full-Time Question Title 11. 8. What is the highest level of education that you have completed? Some High School or less High School Graduate or GED Some College - No degree 2 yr College Degree / Associates 4 yr College Degree / Bachelors Post Graduate Work / Degree Question Title 12. Have you ever been diagnosed with any of the following or had a diagnosis confirmed by a physician? Please select all that apply. Pulmonary Arterial Hypertension (PAH) Dissection (tear in the Aorta) Abdominal pain Anchiall Psoriasis Anxiety Disorders Arthritis Attention Deficit Hyperactivity Disorder (ADHD) Back problems Bipolar disorder Chronic Myeloid Leukemia (CML) Crohn’s Disease (CD) Depression Diabetes Disorders of lipid metabolism Dontiolefiesis Eating Disorders End Stage Renal Disease Gastrointestinal disorders Heart Failure Hemophilia A Hemophilia B Hepatitis A Hepatitis B Hepatitis C HIV Hydrocephalus Hydrolinquitis Hyperhidrosis Hypertension Infertility Irritable Bowel Syndrome (IBS) Liver disease Non-traumatic joint disorders Non-specific chest pain Overweight/ Obesity Parkinson's Disease Plaque Psoriasis (Ps) Psoriatic Arthritis (PsA) Rheumatoid Arthritis (Ra) Schizophrenia Other (Please Specify): None of these Question Title 13. Have you ever been diagnosed with preeclampsia? Yes No Next
