PHX - National Heart Conditions Study - February 2012

1. Conditions

On this page, please indicate whether or not you have been diagnosed with the following conditions:

Upcoming National PAID Telephone Study - February 2012

Thank you for taking the time to answer these brief questions. As always, we appreciate your input as a valuable Plaza Research respondent.

We are currently recruiting for individuals 18+ who have various Heart Conditions. This study is an upcoming telephone survey that will last approximately 60 minutes. There are various times for the interviews to take place between February 6th - 14th, 2012. The honorarium is $75.00 for your participation and a check will be mailed directly to your place of residence. Please note, the Phoenix office will call you in reference to this study.

THIS IS THE PRE-SCREENER SURVEY. Completing this pre-screener survey does NOT automatically qualify you. IF you qualify based on the answers provided in this pre-screener, 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. Please enter your contact information below:

First Name:

Last Name:

State:

Primary Phone Number

Secondary Phone Number:

Email Address:

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* 2. High Blood Pressure?

Yes

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* 3. Diabetes?

Yes

If yes, what type?

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* 4. High Cholesterol?

Yes

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* 5. COPD?

Yes

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* 6. Asthma?

Yes

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* 7. Irregular Heart Rhythms?

Yes

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* 8. Lung Disease?

Yes

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* 9. Any Type of Cancer?

Yes

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* 10. Heart Disease?

Yes