| First name: |
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| Last name: |
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| E-mail: |
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| Date of birth: |
-- mm/dd/yyyy |
| Home phone: |
(
)
|
| Work phone: |
(
)
|
| Cell phone/pager: |
(
)
|
| Home Zip Code: |
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| Occupation: |
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| Employer: |
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| Gender: |
Male
Female |
| Marital status: |
Single
Married
Divorced
Widowed |
| Highest level of education: |
Some High School, No Diploma
High School Diploma
2 -Year College Degree
4-Year College Degree
Post Graduate Degree |
| Ethnic background: |
Non-Hispanic White
Black Afro-Caribbean
Hispanic Black
Black African American
Hispanic White
Asian
Other
If Hispanic, what is your Latin-American
country of origin?
|
|
National background: |
What
country were you born in?
|
| Employment status: (check all that apply) |
Full Time
Part Time
Homemaker
Student
Retired
Unemployed |
| Total household income: |
Under $25,000
$25,000 - $45,000
$45,000 - $75,000
$75,000 - $100,000
$100,000 - $125,000
$125,000 - $150,000
$150,000 - $200,000
Over
$200,000 |
| Political party: |
Republican
Democrat
Independent
Other |
| Do you have pets? |
No Pets
Cat(s)
Dog(s)
Other |
| Do you use a computer? |
Yes
No |
| What type of computer do you use at work? |
PC
Mac
I don't use a computer at work |
| What type of computer do you use at home? |
PC
Mac
I don't use a computer at home |
|
What
kind of Internet service
do you have at home? |
Dial-up
DSL
Cable
I do not have Internet service at home |
| Name of Service Provider: |
|
| Do you consume alcoholic beverages? |
Yes
No |
| If yes, which of these do you drink regularly? |
Beer
Wine
Tequila
Vodka
Scotch
Rum
Gin
Cognac |
| Do you smoke cigarettes? |
Yes
No If you smoke
please tell us what brand you prefer:
|
| How often do you exercise? |
once a month or less
2-3 times/month
once a week
2-3 times/week
4-6 times/week
7 times a week |
|
Have you
ever been diagnosed with any medical
conditions (e.g. cholesterol, diabetes, GERD,
etc)? |
Yes
No If
you checked Yes, please tell us what
conditions:
|
|
What
medications, if any, do you take? |
prescription medication
herbal remedies
over the counter
vitamins
do not take any medication |
|
Do you wear
any of the following? |
glasses
contacts
both
neither |
| Please list all of the automobiles currently driven in your household: |
|
| Do you have any children under the age of 18 living at home with you? |
Yes
No |
| If yes, what are their genders and dates of birth? |
Boy
Girl Date of birth (mm/dd/yyyy):
|
Boy
Girl Date of birth (mm/dd/yyyy):
|
Boy
Girl Date of birth (mm/dd/yyyy):
|
Boy
Girl Date of birth (mm/dd/yyyy):
|
| How did you find out about this website and form? |
Search Engine
Banner Ad
Found while browsing the Internet
Referred by someone
If
referred by someone, please tell us who:
|
