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.

Question Title

* 1. Contact information

Question Title

* 2. Please describe your employment status

Question Title

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

Question Title

* 4. What age range do you fall into?

Question Title

* 5. What is your exact age?

Question Title

* 6. What is your gender?

Question Title

* 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.

Please "like" us on Facebook to receive live updates for upcoming PAID studies!!!!

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

Question Title

* 8. ******FOR COMPANY USE ONLY******
(Please press next)

T