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Email Address
Date of Birth
Home Address
Home Phone Number
Work Phone Number
Work Phone Number
Cell Phone Number
Gender
Which of the following categories includes your age?
Into which ethnic category do you fall?
Marital Status
Children: Please list gender, age and current grade in school for each child.
Education
Current Occupation
Employment Status
Total Household Income
Which non-alchoholic beverages do you drink?
Do you rent or own your home?
Pets
Vehicle 1: Please indicate if you own or lease this vehicle and the year, make and model of vehicle.
Vehicle 2: Please indicate if you own or lease this vehicle and the year, make and model of vehicle.
Vehicle 3: Please indicate if you own or lease this vehicle and the year, make and model of vehicle.
Who is your cell phone provider?
What type of TV service do you have at home?
Do you have a smartphone? If so, which one?
Which of the following credit/debit cards do you have?
Do you suffer from any of the following medical conditions?
When are you available to participate in focus groups?
Would you be willing to participate in studies where we come to your home?