Health Conditions
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: Thurs/November 17th, Fri/November 18th OR Sat/Novmber 19th
Time: 1-HR 15-Mins during the working day (7:45AM-3:45PM openings)
Compensation: $150 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 *
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 *
If not applicable, enter N/A
What is your job title? *
If not applicable, enter N/A
What is the name of the company/organization you work for? *
If not applicable, enter N/A
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
PLEASE SELECT THE FOLLOWING IN YOUR HOUSEHOLD.... *
If chosen, we are conducting a non-clinical research study to evaluate an investigational drug delivery device.  During this study you will be given brief instructions about the use of the device, and following that instruction you will complete tasks that involve pressing buttons and control elements on a model of the drug delivery device. The study will only involve prototype models of the device. The models will not contain any needles, drug, or placebo.  Prior to the start of the actual study procedures, you will be informed about any risks associated with the study device and required to sign a consent form detailing these risks.  The researchers will make every effort to ensure your safety during the interview.  With your permission, your study session will be documented for accurate research reporting through video and audio recording. However, your identity will be kept private, and the recording will not be shared with anyone outside of the research team. All responses given during the study session will be strictly confidential.  Do you agree to this? *
0.       Do you have an allergy to latex or dry natural rubber? *
1. Have you participated in any usability study of this type in the last 6 months? *
2.  Now I would like to talk a bit about your health. What medical conditions have you been diagnosed with? *
Required
3.  When you were formally diagnosed with high LDL cholesterol? *
4.  Are you currently taking medication for high cholesterol? *
 5.  What medication are you currently taking for high cholesterol? *
 6.  How long have you been taking your current medication for High Cholestrol? *
7. How do you receive your medications? *
 8.  We are interested in talking to a mix of people who have experience with injecting themselves or others with medication, and those who do not have this experience. Have you ever injected yourself or anyone else with any medication? *
9. Do you currently inject yourself with any medications? *
If yes, how long ago/how long? *
ie. 2 yrs ago for 3 yrs (If not applicable enter NA)
10. Where on your body do you or did you inject? *
Required
11.   Have you administered medication using the following? *
12. What Medication(s) do you currently, or have you previously, injected? *
(If not applicable enter NA)
13.  What is your Body Mass Index or BMI? *
14.  What is your height in inches? *
15.  What is your weight in pounds? *
3.  How many years has it been since you were first diagnosed with osteoporosis? *
ie. 5 yrs (if not applicable enter N/A)
 4. What are the names of the prescription medications you are CURRENTLY taking for your osteoporosis?   *
5. Which of these following medications have you EVER taken? *
Required
 6. For how long have you been taking medications for your osteoporosis (combined length from ‘Current’ and ‘Former’ medications)? *
ie. 10 yrs (if not applicable enter N/A)
 7.  How do you receive your medications? *
8. Who currently prepares and administers this osteoporosis medication? *
14. Are you willing to self-inject? *
15. Have you experienced a bone fracture within the last 6 years? *
13. Can you speak and read English fluently? *
16. Please tell me which of the following conditions you have: (Visual) *
Required
17.  Please tell me which of the following conditions you have: (Auditory) *
Required
18. Please tell me which of the following conditions you have: (Dexterity) *
Required
19. If chosen, the study will require the placement of small sensors on your forearm. If your forearm has a lot of hair, it may be necessary to shave a small (~1 inch) patch of hair to get the sensor to stick. Are you comfortable having a small patch of hair shaven if it is necessary? *
20. We are interested in enrolling people with varying degrees of dexterity in their hands/wrists. I will ask you some questions about common activities. Please rate your ability to perform them today without the help of any assistive device. There is a rating scale of:  0 = Yes, without difficulty 1 = Yes, with a little difficulty 2 = Yes, with some difficulty 3 = Yes, with much difficulty 4 = Nearly impossible to do 5 = Impossible
Can you hold a bowl? *
Yes, without difficulty
Impossible
Can you seize a full bottle and raise it? *
Yes, without difficulty
Impossible
Can you hold a plate full of food? *
Yes, without difficulty
Impossible
Can you pour liquid from a bottle into a glass? *
Yes, without difficulty
Impossible
Can you unscrew the lid from a jar opened before? *
Yes, without difficulty
Impossible
Can you cut meat with a knife? *
Yes, without difficulty
Impossible
Can you prick things well with a fork? *
Yes, without difficulty
Impossible
Can you peel fruit? *
Yes, without difficulty
Impossible
Can you button your shirt? *
Yes, without difficulty
Impossible
Can you open and close a zipper? *
Yes, without difficulty
Impossible
Can you squeeze a new tube of toothpaste? *
Yes, without difficulty
Impossible
Can you hold a toothbrush efficiently? *
Yes, without difficulty
Impossible
Can you write a short sentence with a pencil or ordinary pen? *
Yes, without difficulty
Impossible
Can you write a letter with a pencil or ordinary pen? *
Yes, without difficulty
Impossible
Can you turn a round doorknob? *
Yes, without difficulty
Impossible
Can you cut a piece of paper with scissors? *
Yes, without difficulty
Impossible
Can you pick up coins from a table top? *
Yes, without difficulty
Impossible
Can you turn a key in a lock? *
Yes, without difficulty
Impossible
31. Are you currently diagnosed and taking medication for Rheumatoid Arthritis, Psoriatic Arthritis, Psoriasis, or Ankylosing Spondylitis? *
5. In the past six months, have you served in any of the following roles?   *
Required
6. In your role, have you provided support for a person with any of the following conditions? *
Required
7. We are interested in talking to a mix of people who have experience with injecting themselves or others with medication, and those who do not have this experience. Have you ever injected yourself or anyone else with any medication? *
16. Other Indications you are diagnosed with? *
Required
1.     Are you currently using a pacemaker or a defibrillator? *
2.     Are you currently using a hearing aid or cochlear implant? *
3.     Are you currently using any other electro-mechanical or mechanical medical device? *
4.     Are you currently using a colonoscopy bag or related collection bag? *
If you have Rheumatoid Arthritis, prescription medication are you currently taking? *
(If not applicable enter NA)
If you have Rheumatoid Arthritis, prescription medication have you previously taken? *
(If not applicable enter NA)
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