Injuries
This questionnaire is a pre-screener to seek eligibility for a market research project. You do NOT get compensated for filling out this form. If you pre-qualify, you will receive a text or email from a Recruiter to call our office.  

Telephone Interviews
Th/July 20th, Fri/July 21st, Mon/July 24th OR Tues/July 25th
Times Currently Available: 9AM-8PM (ET) 1-HR

Compensation: $75.00 Pre-Paid Visa (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 *
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 *
Apple iPhone 7 Plus
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 *
If not applicable, enter N/A
What is your job title? If unemployed enter previous job title. *
If not applicable, enter N/A
What is the name of the company/organization you work for? If unemployed enter previous *
If not applicable, enter N/A
If you are currently working, what industry do you work in? *
If not applicable, enter N/A
(IF MARRIED OR CO-HABITATING) What is your spouse or partner’s current occupation? What Industry are they currently working in? *
Example: FT/Bus Driver/Transportation (If not applicable, enter N/A)
What best represents your households annual income before taxes? (By this we mean all income brought into the home by all household members) *
4. Which of the following best represents your current 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? *
If yes, how old are they? *
Children currently living in YOUR HOUSEHOLD
Required
PLEASE SELECT THE FOLLOWING IN YOUR HOUSEHOLD.... *
2a.   Have you personally ever sustained a fracture which required surgery on any of the following parts of your body?   *
Required
2a.   Has anyone you personally know ever sustained a fracture which required surgery on any of the following parts of their body?   *
Required
2b.   To correct the fracture, did the surgeon utilize an implant (e.g. a plate or a nail) to fix the affected bone?   *
2c.   When did you undergo surgery to correct this fracture?   *
2d. How did the fracture occur?   *
If not applicable enter NA
2d. How did the fracture occur?   *
2e.    Was the surgery paid for via workers comp insurance for a work related injury?   *
2f. Was the surgery performed…. *
3.   When you had this surgery what was your health insurance situation?   *
where are all the working members of your household     employed?   Where are any other working members of your household             employed? *
IE. Spouse/Laborer/ABC Construction, Roommate/Teacher/North High School
6.   Sometimes the type of work people do affects their opinions.  Do you, or does       any member of your immediate family work for:   *
Required
A1a. Do you currently have a smartphone, or a phone that can download apps?   *
A1b. Does your smartphone have a data plan that gives you access to the internet and the ability to send emails without Wifi?   *
A1c. When was the last time that you downloaded an app?   *
A2a. Do you have any of the following devices? *
Required
A2b. Do you currently have daily access to the internet at home or at work? *
A2c. Do you currently have high speed internet access (i.e., DSL or Broadband) not dial up? *
 A3a. Do you currently own or have access to a digital camera?   *
A3b. Have you uploaded a photo from a digital camera OR a cell phone camera to a                computer in the past 6 months? *
A3c. How often do upload photos  to your computer or to a website? *
A4. What internet browser do you use? *
A6 Excluding your time checking email, how much time on average do you spend on the internet per day? *
If chosen, incentive can take up to 6-8 weeks after project completion.  Do you agree to this? *
What is your current mailing address to receive incentive? *
ie. 143 Smith Street Floor 3 Merrick, NY 11566
Any apt info?
Do you have High Lipid Levels or High Triglycerides? (ie. over 200) *
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