Fields marked with an asterisk (* ) are required
* Please Tell Us How you heard about Shugoll Research?
Family or Friend
Online Source
Print Media
Recruited by Phone
Other
His or Her First and Last Name
Demographic and Contact Information
* First Name
Middle Initial
* Last Name
Prefix or Suffix
Mr.
Mrs.
Ms.
Mss.
Dr.
Jr.
Md.
Prof.
Sr.
* Home Phone
Work Phone
Ext.
Cell Phone
May we send you brief text messages when we are recruiting for a study that you may qualify for?
Yes
No
Home Address
Street
* City
* State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
* Zip Code
* County or Ward
* Primary Email
Secondary Email
* Date of Birth
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
01
02
03
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05
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16
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18
19
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21
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24
25
26
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28
29
30
31
Year
Before 1925
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
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1945
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1959
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1961
1962
1963
1964
1965
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1967
1968
1969
1970
1971
1972
1973
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1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
* Gender
Male
Female
* Ethnicity or Race
African American
Asian American
Asian Pacific-Islander
Caucasian
Hispanic
Hispanic-Spanish Speaking
Other
Unknown/Refused
Extended Demographics
Housing Type
Own Single Family Home
Rent Single Family Home
Own Apt/Condo
Rent Apt/Condo
Rent Townhome
Own Townhome
Own Other
Rent Other
Unknown
* Marital Status
Married
Single
Divorced/Separated
Widowed
Partnered
Unknown
Party Affiliation
Democrat
Republican
Independent
Other
Unknown/refused
Household Income
Less than 10,000
10-19,999
20-29,999
30-39,999
40-49,999
50-59,999
60-69,999
70-79,999
80-89,999
90-99,999
100-119,999
120,000-149,999
150,000-199,999
200,000-249,000
250,000-299,000
300,000 +
Refused
Unknown
* Highest Level of Education Achieved
Less than HS
High School Graduate
Some College
College Degree
Graduate Work
Unknown
Primary Language
English
Amharic
Arabic
Armenian
Chinese - Cantonese
Chinese - Mandarin
Creole
Croatian (South Slavic)
Danish
Dutch
Farsi
Filipino
Finnish
French
German
Greek
Gujarati
Hebrew
Hindi
Hungarian
Korean
Polish
Portuguese
Punjabi
Romanian
Russian
Sign Language (English)
Slovak (Slovakian)
Spanish
Tagalog
Tamil
Telugu
Turkish
Urdu
Uyghur
Yiddish
Yoruba
Other
Other languages spoken (Select all that apply. Hold down the <Ctrl> key to make multiple selections.)
English
Amharic
Arabic
Armenian
Chinese - Cantonese
Chinese - Mandarin
Creole
Croatian (South Slavic)
Danish
Dutch
Farsi
Filipino
Finnish
French
German
Greek
Gujarati
Hebrew
Hindi
Hungarian
Italian
Japanese
Korean
Polish
Portuguese
Punjabi
Romanian
Russian
Sign Language (English)
Slovak (Slovakian)
Spanish
Tagalog
Tamil
Telugu
Turkish
Urdu
Uyghur
Yiddish
Yoruba
Other
Number of people living in your household
1
2
3
4
5
6
7
8
9 or more
Do you have any children 24 years old or younger?
Yes
No
Child One:
Gender
Male
Female
Birthdate
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
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18
19
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25
26
27
28
29
30
31
Year
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Child Two:
Gender
Male
Female
Birthdate
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
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17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Child Three:
Gender
Male
Female
Birthdate
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Child Four:
Gender
Male
Female
Birthdate
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Employment Information
* What is your current employment status?
Full time
Part time
Homemaker
Student
Retired
Disabled
Not employed
Are you a:
Doctor
Nurse
Federal Employee
Any Other
Doctor
Year you finished Residency
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
Primary practice setting
Clinic
Hospital - Academic
Hospital - Community
Office - Group
Office - Solo
Medical Specialty(ies) (Select all that apply. Hold down the <Ctrl> key to make multiple selections.)
Allergist
Anesthesiologist
Cardiologist
Dematologist
Ear Nose Throat
Emergency Medicine
Endocrinologist
Family Medicine
Gastroenterology
General Practice
Geriatrics
Hematology
Hospitalist
Immunology
Infectious Diseases
Internal Medicine
Interventional Cardiologists
Mental Health Clinic Psychiatrist
Neonatology
Nephrology
Neurology
Obstetrics & Gynecology
Oncology, Medical
Oncology, Radiation
Ophthalmology
Osteopathic Manipulation
Pain Management
Pathologist
Pediatrics
Podiatry
Psychiatry
Pulmonary Diseases
Radiology
Radiology,Interventional
Reproductive Endocrinology
Rheumatology
Surgery, General
Surgery, Orthopedic
Surgery, Transplant
Surgery, Trauma
Surgery,Cardiovascular
Surgery,Colorectal
Surgery,Neuro
Surgery,Oncology
Surgery,plastic
Urologist
Hospital Affiliation(s) (Select all that apply. Hold down the <Ctrl> key to make multiple selections.)
Alexandria
Childrens (Northern Virginia)
Childrens National Medical Center
Doctors Community
Fair Oaks
Fairfax
Frederick Memorial
George Washington Univ. Medical Center
Georgetown University
Hadley Memorial
Holy Cross
Howard County
Howard University
Johns Hopkins
Laurel Regional
Loudon
Malcolm Grow
Montgomery General
Mt.Vernon
National Naval Medical Center
National Rehabilitaton
Potomac Hosp
Prince George's Hospital
Prince William
Providence
Psychiatric Institute
Reston
Shady Grove Adventist
Sibley Memorial
Southern Maryland
St Elizabeth
Suburban
United Health Care
Veterans Administration Medical Center
Virginia Hospital Center
Walter Reed Army Medical Center
Washington Adventist
Washington Hospital Center
Woodbridge
Nurse
Specialty(ies) (Select all that apply. Hold down the <Ctrl> key to make multiple selections.)
Assisted Living
Dermatologist
Diabetes Educators
Dialysis
Family Medicine
General Practice
Home Health Care
Hospital Allergist
Hospital Anesthesiologist
Hospital Cardiologist
Hospital Ear Nose Throat
Hospital Emergency Medicine
Hospital Endocrinologist
Hospital Gastroenterology
Hospital Geriatrics
Hospital Immunology
Hospital intensivist
Hospital Internal Medicine
Hospital Neurology
Hospital Obstetrics & Gynecology
Hospital Oncology
Hospital Pediatrics
Hospital Pulmonary Diseases
Hospital Radiology
Hospital Staff, All Other
Infection Control
Infectious Diseases
Intensive Care Unit
Mental Health Case Managers
Ophthalmology
Private Allergist
Private Cardiologists
Private Dermatologists
Private Ear Nose Throat
Private Endocrinologist
Private Gastroenterology
Private Geriatrics
Private Immunology
Private intensivist
Private Internal Medicine
Private Neurology
Private Obstetrics & Gynecology
Private Oncology
Private Pediatrics
Private Primary Care
Private Pulmonary Diseases
Private Radiology
Psychiatry
Rheumatology
Sterile Processing Techs
Surgery
Urologist
Year you started practicing
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
Occupation
Registered Nurses (RNs)
Nurse Anesthetists
Nurse Practitioners
Nurse Midwives
Nurse (LPN)
Nursing Aides, Orderlies, and Attendants
Federal Employees
Which Department or Agency do you work for?
Department of Agriculture (USDA)
Department of Commerce (DOC)
Department of Defense (DOD)
Department of Education (ED)
Department of Energy (DOE)
Department of Health and Human Services (HHS)
Department of Homeland Security (DHS)
Department of Housing and Urban Development (HUD)
Department of Justice (DOJ)
Department of Labor (DOL)
Department of State (DOS)
Department of the Interior (DOI)
Department of the Treasury
Department of Transportation (DOT)
Department of Veterans Affairs (VA)
Federal Judiciary
Independent Agency
US Congress
What specific Agency or Group are you part of?
What is your Occupation?
Architecture and Engineering Occupations
Arts, Design, Entertainment, Sports, and Media Occupations
Building and Grounds Cleaning and Maintenance Occupations
Business and Financial Operations Occupations
Community and Social Service Occupations
Computer and Mathematical Occupations
Construction and Extraction Occupations
Education, Training, and Library Occupations
Farming, Fishing, and Forestry Occupations
Food Preparation and Serving Related Occupations
Healthcare Practitioners and Technical Occupations
Healthcare Support Occupations
Installation, Maintenance, and Repair Occupations
Legal Occupations
Life, Physical, and Social Science Occupations
Management Occupations
Military Specific Occupations
Non-Profit and Public Affairs Specific Occupations
Office and Administrative Support Occupations
Personal Care and Service Occupations
Production Occupations
Protective Service Occupations
Sales and Related Occupations
Transportation and Material Moving Occupations
Please select below:
Please select below:
All Others
What is your Occupation?
Architecture and Engineering Occupations
Arts, Design, Entertainment, Sports, and Media Occupations
Building and Grounds Cleaning and Maintenance Occupations
Business and Financial Operations Occupations
Community and Social Service Occupations
Computer and Mathematical Occupations
Construction and Extraction Occupations
Education, Training, and Library Occupations
Farming, Fishing, and Forestry Occupations
Food Preparation and Serving Related Occupations
Healthcare Practitioners and Technical Occupations
Healthcare Support Occupations
Installation, Maintenance, and Repair Occupations
Legal Occupations
Life, Physical, and Social Science Occupations
Management Occupations
Military Specific Occupations
Non-Profit and Public Affairs Specific Occupations
Office and Administrative Support Occupations
Personal Care and Service Occupations
Production Occupations
Protective Service Occupations
Sales and Related Occupations
Transportation and Material Moving Occupations
Please select below:
Please select below:
What industry do you work in?
Agriculture, Forestry, Animal Care and Fishing
Automotive
Communication
Conglomerate
Construction
Education
Engineering
Finance
Food Service
Government - Federal
Government - State and Local
Healthcare & Medicine
Information Technology and Computers
Insurance
Law Enforcement
Legal
Life and Plant Sciences
Manufacturing - All other
Manufacturing - Defense
Marketing / Advertising
Media
Mining and Extraction
Pharmaceuticals & Biotechnology
Public Policy
Real Estate
Religion
Retail - All Other
Retail - Apparel
Retail - Automotive
Services - Entertainment
Services - Travel
Sevices - All Other
Transportation - Airline
Transportation - All Other
Utilities
Wholesale
Other Employment Questions
Job Title (i.e. Managing Partner)
What is the name of your company?
Work Address
Street
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
County or Ward
Fax number
What is your company’s annual revenue or your agency’s annual budget?
Under $1 Million
$1 Million to $9 Million
$10 Million to $49 Million
$50 Million to $99 Million
$100 Millon or more
How many employees work in your organization?
1-10 employees
11-99 employees
100-249 employees
250-499 employees
500-999 employees
1,000 or more employees
How many business trips do you take a year?
None
1-4
5-9
10-19
20 or more
Do you own your own company?
Yes
No
Consumer Information
Do you own an automobile?
Own
Lease
Do not own or lease a vehicle
Primary automobile make, model & year
Make
ACURA
ALFA-ROMEO
AM/AMC
ASTON MARTIN
AUDI
BENTLEY
BMW
BUICK
CADILLAC
CHEVROLET
CHRYSLER
DAEWOO
DAIHATSU
DATSUN
DODGE
EAGLE
FERRARI
FORD
GEO
GMC
HONDA
HYUNDAI
INFINITI
ISUZU
JAGUAR
JEEP
KIA
LAMBORGHINI
LAND ROVER
LEXUS
LINCOLN
LOTUS
MAZARETTI
MAZDA
MERCEDES-BENZ
MERCUR
MERCURY
MGB
MINI COOPER
MITSUBISHI
NISSAN
OLDSMOBILE
PEUGEOT
PLYMOUTH
PONTIAC
PORSCHE
ROLLS-ROYCE
SAAB
SATURN
SCION
STERLING
SUBARU
SUZUKI
TOYOTA
TRIUMPH
VOLKSWAGON
VOLVO
YUGO
OTHER
NONE
Model
Year
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
Older than 1996
Options? (Select all that apply. Hold down the <Ctrl> key to make multiple selections.)
Air Conditioning
Dual Air Bags
Heated Seats
Leather Interior
Navigation System
OnStar
Satellite Radio
Secondary automobile make,model & year
Make
ACURA
ALFA-ROMEO
AM/AMC
ASTON MARTIN
AUDI
BENTLEY
BMW
BUICK
CADILLAC
CHEVROLET
CHRYSLER
DAEWOO
DAIHATSU
DATSUN
DODGE
EAGLE
FERRARI
FORD
GEO
GMC
HONDA
HYUNDAI
INFINITI
ISUZU
JAGUAR
JEEP
KIA
LAMBORGHINI
LAND ROVER
LEXUS
LINCOLN
LOTUS
MAZARETTI
MAZDA
MERCEDES-BENZ
MERCUR
MERCURY
MGB
MINI COOPER
MITSUBISHI
NISSAN
OLDSMOBILE
PEUGEOT
PLYMOUTH
PONTIAC
PORSCHE
ROLLS-ROYCE
SAAB
SATURN
SCION
STERLING
SUBARU
SUZUKI
TOYOTA
TRIUMPH
VOLKSWAGON
VOLVO
YUGO
OTHER
NONE
Model
Year
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
Older than 1996
Options? (Select all that apply. Hold down the <Ctrl> key to make multiple selections.)
Air Conditioning
Dual Air Bags
Heated Seats
Leather Interior
Navigation System
OnStar
Satellite Radio
Do you own any of the following vehicles? (Select all that apply. Hold down the <Ctrl> key to make multiple selections.)
Motorcycle
Sports Car
Truck or Van
Which of the following beverages do you drink? (Select all that apply. Hold down the <Ctrl> key to make multiple selections.)
Alcoholic Energy Drinks
Beer - Domestic
Beer - Imported
Brandy
Coffee (Made at home)
Coffee (Purchased at a Coffee Shop)
Energy Drinks
Fruit Drinks / Pre-Bottled Smoothies
Gin
Liqueurs
Malt Liquor
Rum
Scotch
Sodas
Sport Drinks
Tea
Tequila
Vodka
Whisky
Wine - Red
Wine - White
Do Not Drink Alcohol
Which of the following electronics do you have in your household? (Select all that apply. Hold down the <Ctrl> key to make multiple selections.)
Blue Ray Disc Player
Bluetooth headset
Cellular Phone
Digital Camera
DVD Player
DVR / Tivo
iPod / Mp3 Player
LCD or Plasma TV
Video Camera
Video Game System
Smartphone - Blackberry
Smartphone - iPhone
Smartphone - All Other
Who is your cellular phone provider?
Alltel
AT&T
Boost Mobile
Jitterbug
Net10
Qwest
Sprint
T Mobile
Tracfone
US Cellular
Verizon
Virgin Mobile
Refused
None
What type of television service do you have in your home?
Cable Television
Fiber-Optic
Satellite Television
Other
None
Who is your television service provider?
Comcast
Cox
Direct TV
RCN
Time Warner Cable
Verizon
Other
Do you use a personal computer?
Do Not Use
Use at Home Only
Use at Work Only
Use at Home and Work
Do you use any of the following types of websites? (Select all that apply. Hold down the <Ctrl> key to make multiple selections.)
Blogs
Forums / Discussion Groups
Photo Sharing
Social Networking Sites
What type of online service do you have?
Dial Up
High Speed - Cable Modem
High Speed - DSL
High Speed- FIOS
Who is your online service provider?
All Dial-Up Providers
AOL
AT&T
CableVision
Cavalier
Comcast
Cox
Direct VT
DSL.net
Earthlink
Juno
MDU Communications
MediaCom
Qwest
RCN
Sprint
Verizon
Vonage
All Others
Which of these financial institutions do you use? (Select all that apply. Hold down the <Ctrl> key to make multiple selections.)
ACADEMY BANK
ADAMS BANK AND TRUST
ALL FIRST FINANCIAL
AMALGAMATED BANK
AMERICAN SECURITY
AMERITRADE
ASTORIA FEDERAL
BANK OF AMERICA
BANK OF THE WEST
BAY-VANGUARD
BB & T
BRANCH BANKING AND TRUST CO.
BURKE & HERBERT
CALVERT
CAPITAL ONE
CAPITOL BANK
CARDINAL BANK
CAROLINA TRUST BANK
CEDAR POINT FEDERAL
CHARLES SCHWAB
CITIBANK
CITIZENS BANK
CITIZENS SAVINGS
COMMONWEALTH
DAMASCUS COMMUNITY
EAGLE BANK
EMIGRANT
EQUITABLE BANK
F&M
FARMERS NATIONAL
FAUQUIER BANK
FEDERAL SAVINGS BANK
FIFTH THIRD BANK
FIRST AMERICAN BANK
FIRST COLUMBIA
FIRST FIDELITY
FIRST MARINER
FIRST STATE BANK
FIRST UNION CORP.
FIRST VIRGINIA BANK
GRAND BANK
HSBC
INDEPENDENCE FEDERAL SAVINGS
INDUSTRIAL BANK
ING
LAFAYETTE
LOYOLA
M & T
MERCANTILE BANK
MIDFIRST
NATIONAL BANK OF GEORGIA
NATIONAL CAPITAL
OBA FEDERAL SAVINGS BANK
OLD LINE BANK
PNC
PRESIDENTIAL
PROVIDENT
SANDY SPRINGS NATIONAL BANK
SUN TRUST
TD BANK GROUP
TOWN & COUNTRY BANK
UFB DIRECT
UNION BANK AND TRUST CO.
UNITED BANK
US BANK
USAA FEDERAL SAVINGS BANK
VIRGINIA COMMERCE
WACHOVIA
WAMU
WASHINGTON FEDERAL
ALL OTHER
NONE
REFUSED
Which of these financial instruments do you use? (Select all that apply. Hold down the <Ctrl> key to make multiple selections.)
401K or Similar
Certificate of Deposit
Financial Planner
Home Equity Loan
Money Market Acct.
Mutual Funds
On-Line Banking
Pension
Stocks or Bonds
All Other
None
Refused
Unknown
Do you have any of the following chronic illnesses or conditions? (Select all that apply. Hold down the <Ctrl> key to make multiple selections.)
ACID REFLUX - GERD
ADHD/ADD
ALCOHOL ADDICTION
ALLERGIES - SEASONAL
ALS OR LOU GEHRIGS
ALZHEIMERS
ANGINA
ANOREXIA
ANXIETY DISORDER
ARTHRITIS - OSTEOARTHRITIS
ARTHRITIS - RHEUMATOID
ASTHMA
ATRIAL FIBRILLATION
BACK PROBLEMS
BIPOLAR DISORDER
BLINDNESS
BULIMIA
CANCER - BLADDER
CANCER - BREAST
CANCER - COLON AND RECTAL
CANCER - ENDOMETRIAL
CANCER - KIDNEY (RENAL CELL)
CANCER - LEUKEMIA
CANCER - LUNG
CANCER - LYMPHOMA
CANCER - MELANOMA
CANCER - OTHER
CANCER - PROSTATE
CANCER - SKIN NONMELANOMA
CANCER - THYROID
CATARACTS
CHOLESTEROL
CHRONIC BRONCHITIS
CHRONIC PAIN
CHRONIC SINUSITIS
COLD SORES
COPD
CORONARY ARTERY DISEASE
CROHN'S DISEASE
DEMENTIA
DEPRESSION
DEVELOPMENTAL DISABILITIES
DIABETES - TYPE I
DIABETES - TYPE II
DIGESTIVE/GASTROINTESTINAL DISORDERS
DRUG ADDICTION
EATING DISORDERS
ED-ERECTILE DYSFUNCTION
EMPHYSEMA
EPILEPSY
FIRBROMYALGIA
FOOD ALLERGIES
GENITAL HERPES
GLAUCOMA
GOUT
GYNECOLOGICAL CONDITIONS
HEARING IMPAIRMENT
HEART DISEASE
HEARTBURN
HEMOPHILIA
HEPATITIS B
HEPATITIS C
HIV/AIDS
HYPERTENSION - HIGH BLOOD PRESSURE
INCONTINENCE
INFERTILITY
INSOMNIA
IRRITABLE BOWEL SYNDROME
KIDNEY DISEASE
LACTOSE INTOLERANCE
LIVER DISEASE
LUPUS
LYME DISEASE
MACULAR DEGENERATION
MIGRAINES
MULTIPLE SCLEROSIS
MUSCULAR DYSTROPHY
OBESITY
OCD - OBSESSIVE COMPULSIVE DISORDER
OSTEOPENIA
OSTEOPOROSIS
OVERACTIVE BLADDER
PANIC DISORDER
PARALYSIS
PARKINSONS
PERSONALITY DISORDER
PHOBIAS
PROSTATE CONDITIONS
PSORIASIS
RESTLESS LEG
ROSACEA
SCHIZOPHRENIA
SHINGLES
SKIN CONDITION
SLEEP DISORDERS
STDS
STROKE
THYROID DISORDER
UTERINE FIBROIDS
VISION IMPAIRMENT
ZOSTER
ALL OTHER
Are you a caretaker for anyone with any of the following illnesses? (Select all that apply. Hold down the <Ctrl> key to make multiple selections.)
ACID REFLUX - GERD
ADHD/ADD
ALCOHOL ADDICTION
ALLERGIES - SEASONAL
ALS OR LOU GEHRIGS
ALZHEIMERS
ANGINA
ANOREXIA
ANXIETY DISORDER
ARTHRITIS - OSTEOARTHRITIS
ARTHRITIS - RHEUMATOID
ASTHMA
ATRIAL FIBRILLATION
BACK PROBLEMS
BIPOLAR DISORDER
BLINDNESS
BULIMIA
CANCER - BLADDER
CANCER - BREAST
CANCER - COLON AND RECTAL
CANCER - ENDOMETRIAL
CANCER - KIDNEY (RENAL CELL)
CANCER - LEUKEMIA
CANCER - LUNG
CANCER - LYMPHOMA
CANCER - MELANOMA
CANCER - OTHER
CANCER - PROSTATE
CANCER - SKIN NONMELANOMA
CANCER - THYROID
CATARACTS
CHOLESTEROL
CHRONIC BRONCHITIS
CHRONIC PAIN
CHRONIC SINUSITIS
COLD SORES
COPD
CORONARY ARTERY DISEASE
CROHN'S DISEASE
DEMENTIA
DEPRESSION
DEVELOPMENTAL DISABILITIES
DIABETES - TYPE I
DIABETES - TYPE II
DIGESTIVE/GASTROINTESTINAL DISORDERS
DRUG ADDICTION
EATING DISORDERS
ED-ERECTILE DYSFUNCTION
EMPHYSEMA
EPILEPSY
FIRBROMYALGIA
FOOD ALLERGIES
GENITAL HERPES
GLAUCOMA
GOUT
GYNECOLOGICAL CONDITIONS
HEARING IMPAIRMENT
HEART DISEASE
HEARTBURN
HEMOPHILIA
HEPATITIS B
HEPATITIS C
HIV/AIDS
HYPERTENSION - HIGH BLOOD PRESSURE
INCONTINENCE
INFERTILITY
INSOMNIA
IRRITABLE BOWEL SYNDROME
KIDNEY DISEASE
LACTOSE INTOLERANCE
LIVER DISEASE
LUPUS
LYME DISEASE
MACULAR DEGENERATION
MIGRAINES
MULTIPLE SCLEROSIS
MUSCULAR DYSTROPHY
OBESITY
OCD - OBSESSIVE COMPULSIVE DISORDER
OSTEOPENIA
OSTEOPOROSIS
OVERACTIVE BLADDER
PANIC DISORDER
PARALYSIS
PARKINSONS
PERSONALITY DISORDER
PHOBIAS
PROSTATE CONDITIONS
PSORIASIS
RESTLESS LEG
ROSACEA
SCHIZOPHRENIA
SHINGLES
SKIN CONDITION
SLEEP DISORDERS
STDS
STROKE
THYROID DISORDER
UTERINE FIBROIDS
VISION IMPAIRMENT
ZOSTER
ALL OTHER
Do you engage in any of the following activities? (Select all that apply. Hold down the <Ctrl> key to make multiple selections.)
Diving
Fishing/Hunting
Golf Equipment
Health/Athletic Club Membership
Paint Ball
Rock Climbing
Running
Sailing
Ski / Snow Board Equipment
Tennis Equipment
What type of health insurance do you have?
Fee-for-Service Plans
Health Maintenance Organizations (HMOs)
None
Point-of-Service (POS)
Preferred Provider Organizations (PPOs)
Unknown
Who is your health insurance provider?
Aetna
Blue Cross/Blue Shield
Celtic life Insurance Company
Cigna Healthcare
Fortis Insurance Company/Assurance
John Alden Life Insurance Company
Kaiser Permanente
National Safety Life
Pharmacists mutual
State Farm Insurance
All Other
Which of the following, if any, types of tobacco do you use? (Select all that apply. Hold down the <Ctrl> key to make multiple selections.)
Chewing
Cigar
Cigarettes
Pipe
None
Do you have a cat or dog?
Cat
Dog
Both
Which of the following grocery stores do you shop at most frequently? (Select all that apply. Hold down the <Ctrl> key to make multiple selections.)
Albertson's
Balducci's
Bloom
Food Lion
Giant
Harris Teeter
Safeway
Shoppers
Super Fresh
Trader Joe's
Whole Foods
Other Health Food Stores
All other
How many leisure trips a year do you take?
1-4
5-9
10-19
20 or more
None
What are your favorite radio stations? (Select all that apply. Hold down the <Ctrl> key to make multiple selections.)
NPR
SATELLITE
WMUC 88.1 FM
WAMU 88.5 FM
WPFW 89.3 FM
WCSP 90.1 FM
WETA 90.9 FM
WGTS 91.9 FM
WBZS 92.7 FM
WKYS 93.9 FM
WARW 94.7 FM
WPGC 95.5 FM
WHUR 96.3 FM
WASH 97.1 FM
WRYR 97.5 FM
WMDM 97.7 FM
WSMD 98.3 FM
WMZQ 98.7 FM
WHFS 99.1 FM
WITH 99.5 FM
WBIG 100.3 FM
WWDC 101.1 FM
WMMJ 102.3 FM
WKIK 102.9 FM
WGMS 103.5 FM
WWZZ 104.1FM
WAVA 105.1 FM
WJZW 105.9 FM
WJFK 106.7 FM
WRQX 107.3 FM
WFSI 107.9 FM
WMAL 630 AM
WKDL 730 AM
WABS 780 AM
WILC 900 AM
SCTN 950 AM
WTEM 980 AM
WWGB 1030 AM
WPLC 1050 AM
WUST 1120 AM
WFAX 1220 AM
WWRC 1260 AM
WDCT 1310 AM
WYCB 1340 AM
WZHF 1390 AM
WOL 1450 AM
WKDV 1460 AM
WTOP 1500 AM
WACA 1540 AM
WKIK 1560 AM
WPGC 1580 AM
WLXE 1600 AM
WPTX 1690 AM
ALL OTHERS
NONE
Do you wear contact lenses?
Yes
No
Do you wear glasses?
Yes
No
Do you own a vacation home?
Yes
No
What is your spouse’s/partner’s employment status?
Full time
Part time
Homemaker
Student
Retired
Disabled
Not employed
What is your spouse’s/partner’s occupation?
Architecture and Engineering Occupations
Arts, Design, Entertainment, Sports, and Media Occupations
Building and Grounds Cleaning and Maintenance Occupations
Business and Financial Operations Occupations
Community and Social Service Occupations
Computer and Mathematical Occupations
Construction and Extraction Occupations
Education, Training, and Library Occupations
Farming, Fishing, and Forestry Occupations
Food Preparation and Serving Related Occupations
Healthcare Practitioners and Technical Occupations
Healthcare Support Occupations
Installation, Maintenance, and Repair Occupations
Legal Occupations
Life, Physical, and Social Science Occupations
Management Occupations
Military Specific Occupations
Non-Profit and Public Affairs Specific Occupations
Office and Administrative Support Occupations
Personal Care and Service Occupations
Production Occupations
Protective Service Occupations
Sales and Related Occupations
Transportation and Material Moving Occupations
Please select below:
Please select below:
What industry does your spouse/partner work in?
Agriculture, Forestry, Animal Care and Fishing
Automotive
Communication
Conglomerate
Construction
Education
Engineering
Finance
Food Service
Government - Federal
Government - State and Local
Healthcare & Medicine
Information Technology and Computers
Insurance
Law Enforcement
Legal
Life and Plant Sciences
Manufacturing - All other
Manufacturing - Defense
Marketing / Advertising
Media
Mining and Extraction
Pharmaceuticals & Biotechnology
Public Policy
Real Estate
Religion
Retail - All Other
Retail - Apparel
Retail - Automotive
Services - Entertainment
Services - Travel
Sevices - All Other
Transportation - Airline
Transportation - All Other
Utilities
Wholesale
Do you use hair coloring products?
Yes
No
Do you use fragrances?
Yes
No
Do you use cosmetics?
Yes
No