Healthcare
This survey is a pre-screening survey to see eligible for a market research Focus Group . You do NOT get compensated for taking this online screener. IF you pre-qualify, you will receive a text, phone call or email from a Recruiter to call our office.  Thank you.

Location: Manhattan
Date: Fri/Feb 26th
Time: 9:45AM-12:40PM, 12:45-3:40PM OR 3:45-6:40PM
Compensation: $135 Visa Gift Card (if chosen)

Times are for reference only, booked by available quotas.
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First Name *
Last Name *
Your Age *
Your Age *
WHAT IS YOUR DATE OF BIRTH? *
MM
/
DD
/
YYYY
Gender *
Ethnicity/Race *
Required
Are you Spanish, Hispanic or Latina/Latina? *
Email *
Cell-Phone Number *
Best Number to Text *
Cell Phone Carrier *
Alternate Number *
Advanced Opinions communicates via text may we text to communicate with you? *
Advanced Opinions communicates via email may we email you to communicate with you? *
State *
The County you Live in (i.e., Lehigh) *
The County you Work in (i.e., Lehigh) *
Your Zip Code where you live *
The Make/Model of your Cell Phone *
Are you currently *
If you are a Student, are you
Clear selection
What is the highest level of education you have completed? *
If you are currently working, please briefly describe your employment *
What is your job title? *
What is the name of the company/organization you work for? *
If you are currently working, what industry do you work in? *
What best represents your households annual income before taxes? (By this we mean all income brought into the home by all household members) *
Marital Status *
What one radio station is your favorite station to listen to for Music? *
What one radio station is your Second favorite station to listen to for Music? *
What one radio station is your Third favorite station to listen to for Music? *
Do you personally have any children currently living in your home under the age of 18? *
If yes, how old are they? *
Required
If yes, what is their age/gender? *
6. DO YOU OR DOES ANY MEMBER OF YOUR HOUSEHOLD WORK FOR . . . *
Required
7A. WE ARE INTERESTED IN HAVING SOME PARTICIPANTS WHO HAVE BEEN INTERVIEWED BEFORE FOR MARKET RESEARCH PURPOSES, AND SOME WHO HAVE NOT.  WHEN WAS THE LAST TIME, IF EVER, THAT YOU WERE INTERVIEWED ALONE OR IN A GROUP FOR MARKET RESEARCH? *
 7B. WHAT ARE ALL OF THE SUBJECTS THAT YOU HAVE EVER DISCUSSED DURING MARKET RESEARCH?     *
8. WHAT TYPE OF MEDICAL INSURANCE, IF ANY, DO YOU HAVE? *
1. TYPE 2 DIABETES                                                             *
9A.   HAVE YOU BEEN DIAGNOSED WITH, OR TOLD BY A DOCTOR THAT YOU HAVE, ANY OF THE FOLLOWING HEALTH CONDITIONS?
2. TYPE 1 DIABETES                                                               *
9A.   HAVE YOU BEEN DIAGNOSED WITH, OR TOLD BY A DOCTOR THAT YOU HAVE, ANY OF THE FOLLOWING HEALTH CONDITIONS?
3. GESTATIONAL DIABETES                                                     *
9A.   HAVE YOU BEEN DIAGNOSED WITH, OR TOLD BY A DOCTOR THAT YOU HAVE, ANY OF THE FOLLOWING HEALTH CONDITIONS?
4. HIGH TRIGLYCERIDES *
9A.   HAVE YOU BEEN DIAGNOSED WITH, OR TOLD BY A DOCTOR THAT YOU HAVE, ANY OF THE FOLLOWING HEALTH CONDITIONS?
5. ENLARGED PROSTATE *
9A.   HAVE YOU BEEN DIAGNOSED WITH, OR TOLD BY A DOCTOR THAT YOU HAVE, ANY OF THE FOLLOWING HEALTH CONDITIONS?
6. DEPRESSION OR ANXIETY *
9A.   HAVE YOU BEEN DIAGNOSED WITH, OR TOLD BY A DOCTOR THAT YOU HAVE, ANY OF THE FOLLOWING HEALTH CONDITIONS?
7. ASTHMA *
9A.   HAVE YOU BEEN DIAGNOSED WITH, OR TOLD BY A DOCTOR THAT YOU HAVE, ANY OF THE FOLLOWING HEALTH CONDITIONS?
8. CHRONIC BRONCHITIS *
9A.   HAVE YOU BEEN DIAGNOSED WITH, OR TOLD BY A DOCTOR THAT YOU HAVE, ANY OF THE FOLLOWING HEALTH CONDITIONS?
9. EMPHYSEMA *
9A.   HAVE YOU BEEN DIAGNOSED WITH, OR TOLD BY A DOCTOR THAT YOU HAVE, ANY OF THE FOLLOWING HEALTH CONDITIONS?
10. COPD (CHRONIC OBSTRUCTIVE PULMONARY DISEASE)   *
9A.   HAVE YOU BEEN DIAGNOSED WITH, OR TOLD BY A DOCTOR THAT YOU HAVE, ANY OF THE FOLLOWING HEALTH CONDITIONS?
11. HEART DISEASE *
9A.   HAVE YOU BEEN DIAGNOSED WITH, OR TOLD BY A DOCTOR THAT YOU HAVE, ANY OF THE FOLLOWING HEALTH CONDITIONS?
13. HIGH BLOOD PRESSURE *
9A.   HAVE YOU BEEN DIAGNOSED WITH, OR TOLD BY A DOCTOR THAT YOU HAVE, ANY OF THE FOLLOWING HEALTH CONDITIONS?
14. HIGH CHOLESTEROL *
9A.   HAVE YOU BEEN DIAGNOSED WITH, OR TOLD BY A DOCTOR THAT YOU HAVE, ANY OF THE FOLLOWING HEALTH CONDITIONS?
15. KIDNEY DISEASE REQUIRING DIALYSIS *
9A.   HAVE YOU BEEN DIAGNOSED WITH, OR TOLD BY A DOCTOR THAT YOU HAVE, ANY OF THE FOLLOWING HEALTH CONDITIONS?
16. OTHER (PLEASE SPECIFY ________) *
9A.   HAVE YOU BEEN DIAGNOSED WITH, OR TOLD BY A DOCTOR THAT YOU HAVE, ANY OF THE FOLLOWING HEALTH CONDITIONS?
1. ORAL PRESCRIPTION DIABETES MEDICATION (PILLS OR TABLETS) *
PLEASE SELECT THE TREATMENT METHOD(S) YOU ARE CURRENTLY USING FOR TYPE 2 DIABETES
2. INJECTABLE NON-INSULIN ANTI-DIABETES MEDICATION (SUCH AS BYETTA, BYDUREON, OR INVOKANA) *
PLEASE SELECT THE TREATMENT METHOD(S) YOU ARE CURRENTLY USING FOR TYPE 2 DIABETES
3. INSULIN *
PLEASE SELECT THE TREATMENT METHOD(S) YOU ARE CURRENTLY USING FOR TYPE 2 DIABETES
4. NO PRESCRIPTION MEDICATIONS *
PLEASE SELECT THE TREATMENT METHOD(S) YOU ARE CURRENTLY USING FOR TYPE 2 DIABETES
 10. PLEASE INDICATE THE AMOUNT OF TIME SINCE DIAGNOSIS OF TYPE 2 DIABETES? *
WHEN IT COMES TO TAKING CARE OF MY HEALTH, I FEEL OVERWHELMED *
 11. THE FOLLOWING STATEMENTS REFER TO YOUR GENERAL FEELINGS ABOUT PRESCRIPTION BIRTH CONTROL.  SELECT FROM A 7-POINT SCALE WHERE 1 MEANS “DISAGREE COMPLETELY”, 7 MEANS “AGREE COMPLETELY”.  
DISAGREE COMPLETELY
AGREE COMPLETELY
I AM FRUSTRATED WITH TRYING TO LOSE WEIGHT *
 11. THE FOLLOWING STATEMENTS REFER TO YOUR GENERAL FEELINGS ABOUT PRESCRIPTION BIRTH CONTROL.  SELECT FROM A 7-POINT SCALE WHERE 1 MEANS “DISAGREE COMPLETELY”, 7 MEANS “AGREE COMPLETELY”.  
DISAGREE COMPLETELY
AGREE COMPLETELY
FAMILY OR SOCIAL GATHERINGS CAN BE PARTICULARLY DIFFICULT FOR ME BECAUSE OF DIABETES *
 11. THE FOLLOWING STATEMENTS REFER TO YOUR GENERAL FEELINGS ABOUT PRESCRIPTION BIRTH CONTROL.  SELECT FROM A 7-POINT SCALE WHERE 1 MEANS “DISAGREE COMPLETELY”, 7 MEANS “AGREE COMPLETELY”.  
DISAGREE COMPLETELY
AGREE COMPLETELY
I AM MORE CONCERNED WITH OTHER HEALTH CONDITIONS THAN I AM WITH MY DIABETES *
 11. THE FOLLOWING STATEMENTS REFER TO YOUR GENERAL FEELINGS ABOUT PRESCRIPTION BIRTH CONTROL.  SELECT FROM A 7-POINT SCALE WHERE 1 MEANS “DISAGREE COMPLETELY”, 7 MEANS “AGREE COMPLETELY”.  
DISAGREE COMPLETELY
AGREE COMPLETELY
I FIND IT DIFFICULT TO KEEP MY MOTIVATION TO MANAGE MY DIABETES *
 11. THE FOLLOWING STATEMENTS REFER TO YOUR GENERAL FEELINGS ABOUT PRESCRIPTION BIRTH CONTROL.  SELECT FROM A 7-POINT SCALE WHERE 1 MEANS “DISAGREE COMPLETELY”, 7 MEANS “AGREE COMPLETELY”.  
DISAGREE COMPLETELY
AGREE COMPLETELY
I AM CONSTANTLY LOOKING FOR NEW INFORMATION TO HELP IMPROVE MY CONTROL OVER DIABETES *
 11. THE FOLLOWING STATEMENTS REFER TO YOUR GENERAL FEELINGS ABOUT PRESCRIPTION BIRTH CONTROL.  SELECT FROM A 7-POINT SCALE WHERE 1 MEANS “DISAGREE COMPLETELY”, 7 MEANS “AGREE COMPLETELY”.  
DISAGREE COMPLETELY
AGREE COMPLETELY
IF I FEEL MY DIABETES MEDICATION IS NOT WORKING, I WILL REQUEST THAT MY DOCTOR PRESCRIBE ME SOMETHING ELSE *
 11. THE FOLLOWING STATEMENTS REFER TO YOUR GENERAL FEELINGS ABOUT PRESCRIPTION BIRTH CONTROL.  SELECT FROM A 7-POINT SCALE WHERE 1 MEANS “DISAGREE COMPLETELY”, 7 MEANS “AGREE COMPLETELY”.  
DISAGREE COMPLETELY
AGREE COMPLETELY
I AM VERY OPEN TO TRYING DIFFERENT MEDICATIONS FOR MY DIABETES *
 11. THE FOLLOWING STATEMENTS REFER TO YOUR GENERAL FEELINGS ABOUT PRESCRIPTION BIRTH CONTROL.  SELECT FROM A 7-POINT SCALE WHERE 1 MEANS “DISAGREE COMPLETELY”, 7 MEANS “AGREE COMPLETELY”.  
DISAGREE COMPLETELY
AGREE COMPLETELY
I WOULD TURN AROUND AND GO HOME IF I REALIZED THAT I FORGOT TO TAKE MY DIABETES MEDICATION *
 11. THE FOLLOWING STATEMENTS REFER TO YOUR GENERAL FEELINGS ABOUT PRESCRIPTION BIRTH CONTROL.  SELECT FROM A 7-POINT SCALE WHERE 1 MEANS “DISAGREE COMPLETELY”, 7 MEANS “AGREE COMPLETELY”.  
DISAGREE COMPLETELY
AGREE COMPLETELY
 12A.   WHICH OF THE FOLLOWING PRESCRIPTION MEDICATIONS FOR TYPE 2 DIABETES HAVE YOU EVER TAKEN?   *
Required
 12B.   WHICH OF THE FOLLOWING PRESCRIPTION MEDICATIONS FOR TYPE 2 DIABETES DO YOU CURRENTLY TAKE?   *
Required
16. THE FOLLOWING QUESTION ASKS YOU TO USE YOUR IMAGINATION.  TAKE A MOMENT TO THINK ABOUT IT – AND PLEASE BE AS CREATIVE AS POSSIBLE WHEN RESPONDING.  THERE ARE NO CORRECT OR INCORRECT ANSWERS HERE – WE ARE JUST LOOKING FOR YOU TO GIVE US YOUR HONEST THOUGHTS AND OPINIONS.  IMAGINE YOU’VE BEEN ASKED TO CHOOSE 3 ITEMS TO INCLUDE IN A TIME CAPSULE TODAY.  THE TIME CAPSULE WILL BE OPENED IN THE YEAR 2200 – AND THESE ITEMS SHOULD REPRESENT YOUR LIFE TO DATE OR THE WORLD IN 2016.  WHAT 3 THINGS WOULD YOU SELECT TO INCLUDE?  WHY? *
IF CHOSEN, DIFFERENT PATIENTS SOMETIMES RESPOND IN DIFFERENT WAYS TO THE SAME MEDICINE, AND SOME SIDE EFFECTS MAY NOT BE DISCOVERED UNTIL MANY PEOPLE HAVE USED A MEDICINE OVER A PERIOD OF TIME.  FOR THIS REASON, WE ARE NOW BEING ASKED TO PASS ON TO OUR CLIENT, THE SPONSORING COMPANY, WHICH IS A MANUFACTURER OF MEDICINES, DETAILS OF ANY SIDE EFFECTS RELATED TO THEIR OWN PRODUCTS THAT ARE MENTIONED DURING THE COURSE OF MARKET RESEARCH.   ALTHOUGH WHAT YOU SAY WILL, OF COURSE, BE TREATED IN CONFIDENCE, SHOULD YOU MENTION DURING THE DISCUSSION A SIDE EFFECT WHEN YOU, OR SOMEONE YOU KNOW, BECAME ILL AFTER TAKING ONE OF OUR CLIENT'S MEDICINES, WE WILL NEED TO REPORT THIS, SO THAT OUR CLIENT CAN LEARN MORE ABOUT THE SAFETY OF ITS MEDICINES. ADVERSE EXPERIENCE INFORMATION PROVIDED IS SHARED WITH REGULATORY AGENCIES, THE SPONSORING COMPANY'S SUBSIDIARIES WORLDWIDE, AND BUSINESS PARTNERS WITH WHOM THE SPONSORING COMPANY HAS CONTRACTUAL AGREEMENTS.  ANY INFORMATION THAT IDENTIFIES THE PATIENT DIRECTLY, SUCH AS THE PATIENT'S INITIALS OR DATE OF BIRTH, WILL BE HANDLED CONFIDENTIALLY.  DO YOU UNDERSTAND THIS INFORMATION AND AGREE TO COMPLY WITH IT? *
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