Exit this survey Join our database 1. Page1 / 1 100% of survey complete. Question Title * 1. Murray Hill National, a market research company, will be in your area soon conducting PAID RESEARCH. We would like to invite you to receive notifications on all studies that might apply to you. All of our research will pay you an incentive. Cash and / or Rewards. We will input your information into our database and contact you if you meet specific criteria. To get started we require at a minimum your contact info. We are asking a host of questions that will assist us in narrowing down which studies / research best suite your profile. We are excited to work with you. Name: Company: Address: Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Country: Email Address: Phone Number: Question Title * 2. What is your profession? Question Title * 3. In what industry do you work? Question Title * 4. Which category below includes your age? 17 or younger 18-20 21-29 30-39 40-49 50-59 60 or older Question Title * 5. What is your gender? Female Male Question Title * 6. What is your ethnicity? Caucasian African American / Black Asian American Indian / Native American Hispanic / Latino Other (please specify) Question Title * 7. Are you a Healthcare Professional? What is your specialty? Nurse CNA NP PA PCP Other Specialty I am not a healthcare professional Yes Yes Nurse Yes CNA Yes NP Yes PA Yes PCP Yes Other Specialty Yes I am not a healthcare professional No No Nurse No CNA No NP No PA No PCP No Other Specialty No I am not a healthcare professional Question Title * 8. What is your specialty? Question Title * 9. What is your approximate average household income? $0-$24,999 $25,000-$49,999 $50,000-$74,999 $75,000-$99,999 $100,000-$124,999 $125,000-$149,999 $150,000-$174,999 $175,000-$199,999 $200,000 and up Question Title * 10. What is your employment status? Question Title * 11. Which of the following best describes your health insurance coverage? Group Health Insurance (through your or your family member's employer) Individual Health Insurance (that you purchased yourself) Medicare / Enrolling in Medicare Medicaid No Health Insurance Military, VA or Federal Employee Question Title * 12. Please pick all that apply Have children under 18 Have children under 5 Drink alcoholic beverages Smoke regular cigarettes Smoke menthol cigarettes Have health insurance I pay for privately Have employer paid health insurance Own home Rent apartment Vote regularly Own a dog or dogs Own a cat or cats Question Title * 13. Do you own an above or in-ground swimming pool? Yes No Question Title * 14. Please check any of the following that apply to you: Cancer Asthma COPD Diabetes Type 1 Diabetes Type 2 Epilepsy Emphysema Incontinence Hypogonadism Parkinson's Disease Sickle Cell Anemia Alzheimer Chronic/Congestive Heart Failure Patients Afib Orthopedic Fabry Disease Cardiomyopathy Plaque Psoriasis (PS) Crohn's Disease Ulcerative Colitis (UC) Hidradenitis Suppurativa (HS) Uveitis Other (please specify) Question Title * 15. Please list the medications you are currently taking... Question Title * 16. Check if you are a caregiver to someone being treated for any of the following Alzheimer Asthma Dementia Cancer Diabetes Type 1 Diabetes Type II Epilepsy COPD Ephysema Chronic/Congestive Heart Failure Afib Orthopedic Other (please specify) Question Title * 17. Have you ever been diagnosed with any of the following or had a diagnosis confirmed by a physician? Please select all that apply. Abdominal Pain Alzheimers Age related memory loss Anchiall Psoriasis Anxiety Disorders Arthritis Attention Deficit Hyperactivity Disorder (ADHD) Back Problems Bipolar Disorder Breast Cancer Cardiomyopathy Crohn’s Disease (CD) Cystic Fibrosis Depression Diabetes Disorders of Lipid Metabolism Dissection (tear in the Aorta) Dontiolefiesis Eating Disorders End Stage Renal Disease Fabry Disease Gastrointestinal Disorders Hemophilia A Hemophilia B Hepatitis A Hepatitis B Hepatitis C HIV Hydrocephalus Hydrolinquitis Hyperhidrosis Infertility Irritable Bowel Syndrome (IBS) Lung Cancer Liver Disease Multiple Sclerosis Non-traumatic Joint Disorders Non-specific Chest Pain Overweight/ Obesity Pancreatitis Parkinson's Disease Plaque Psoriasis (Ps) Prostate Cancer Psoriatic Arthritis (PsA) Pulmonary Arterial Hypertension (PAH) Rheumatoid Arthritis (Ra) Schizophrenia None of these Chronic lymphocytic leukemia (CLL) Glioblastoma metforme Any cancer cITP chronic immune thrombocytopenia Pulmonary Embolism Deep vein Thrombosis A-fib Bladder Cancer Colorectal Cancer Skin Cancer Melanoma. Brain Cancer Cervical cancer. Ovarian Cancer Non-Hodgkin lymphoma. Pancreatic Cancer Thyroid cancer Uterine cancer Gastric Cancer Esophageal Cancer Breast Cancer Liver Cancer Kidney Cancer Traumatic Brain Injury Leukemia Non Hodgkin Lymphoma Hodgkin Lymphoma deep vein thrombosis pulmonary embolism Question Title * 18. Have you ever been diagnosed with any of the following or had a diagnosis confirmed by a physician? Please select all that apply. Uterine fibroids (diagnosed by HCP or ultrasound) Hypothyroidism Endometreosis Cardiomyopathy Question Title * 19. Do you use Snuff or Snus products? Yes No Question Title * 20. Can you tell me which of the following products you use in your household? Soda Diapers -Cloth only Disposable Training Pants Paper Plates Packaged Meat Incontinence Products Shampoo and Conditioner Question Title * 21. Please list the ages of all people living in your household: #1: #2: #3: #4: #5: Question Title * 22. Do you experience pain in any of the following areas of your body: Neck Shoulder Arm Other (please specify) Question Title * 23. Have you ever suffered a HEART ATTACK, and if so, how long ago? 2 - 5 years ago 5 - 10 years ago Over 10 years ago I have never suffered a heart attack Question Title * 24. We now require proof of diagnosis for all studies related to medical conditions. Are you willing to provide proof of medication and/or a doctor's note? Yes No Question Title * 25. Please list all vehicles in your household...include motorcycles and ATV or farm equipment Vehicle 1 Year, Make, Model Vehicle 2 Year, Make, Model Vehicle 3 Year, Make, Model Vehicle 4 Year, Make, Model Question Title * 26. When was the last time you attended a concert at any venue Less than 6 months ago 6 months to one year One year or more Never Question Title * 27. Would you be open to taking a short video for us? We call it a hello video. This encourages some of our clients to call you quicker than others. Yes No Done
