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Medical Conditions - June 2012

Thank you for taking the time to answer these brief questions. As always, we appreciate your input as a valuable Plaza Research respondent. Plaza Research San Francisco is currently looking for patients, caregivers and family members of certain medical conditions. This will be a 90-minute in home interview and will pay $125-$150 for your time.

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

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* 2. Please describe your employment status

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* 3. Employment Information (if unemployed please write "n/a")

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* 4. What age range do you fall into?

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* 5. What is your exact age?

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* 6. What is your gender?

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* 7. Please select all that apply to you....

  I suffer from this condition I am the caretaker for someone who suffers from this condition I am the family member of someone who suffers from this condition None of these apply to me
Congestive Heart Failure
Diabetes
Dementia
Lung Cancer
HIV/AIDS
**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.

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

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* 8. ******FOR COMPANY USE ONLY******
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