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1. Health & Wellness - July 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 Health & Wellness that you maybe in 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 females ages 18-75. This is a 3 week online diary with a possible follow up in-home interview. The honorarium is $350.00 for the online diary portion and an additional incentive for the in-home portion if chosen.

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. 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 current employment status?

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* 6. Do you or someone in your household have a serious health condition that requires treatment beyond prescription medication and over-the-counter medication such as injections, infusions, IV treatments, chemo/radiation treatments, dialysis, etc.?

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* 7. So we can get a representative mix, how would you describe your ethnic background?

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* 8. What is your marital status?

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* 9. Do you have children living at home of whom you are the primary caretaker?

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* 10. Are you, yourself, the person responsible for making the decisions and for purchasing the products related to health, wellness, feminine care, oral care, beauty care and person needs for you and your household?

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* 11. Which of the following health conditions have you or a member of your household experienced in the past 12 months?

  Myself A member of my household Neither myself nor a member of my household
Alzheimer's
Arthritis
Cancer
Chronic Fatigue
Depression
Down's Syndrome
Diabetes
Fibromyalgia
Frequent back or neck pain
Hepatitis A, B, or C
HIV/Aids
High Cholesterol
High Blood Pressure
Irritable Bowel Syndrome
Lupus
Migraines
Multiple Sclerosis
No chronic health conditions

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* 12. Are you currently pregnant?

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* 13. Please rate the following statements...

  Strongly Agree Agree Neither Agree Disagree Strongly Disagree
I actively seek information about nutrition and healthy diets
I eat the foods I like regardless of calories
I exercise regularly because it is good for me

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* 14. What is your ethnicity?

**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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* 15. ******FOR COMPANY USE ONLY******
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