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Consumer Questionnaire
Step
1
of
15
6%
*
are required fields
Name
*
First
Last
Email address
*
(must be a valid email address to continue)
Mobile (preferred) or best #: (required)
*
(XXX-XXX-XXXX)
Alternate phone #:
Gender:
*
Male
Female
In what year were you born?
Choose Year
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
In what country do you live?
*
United States
Canada
Mexico
United Kingdom
(Most of our studies are conducted in the countries listed)
In what state do you live?
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
What is your 5-digit zip code?
*
In what Province do you live?
Choose Answer
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland & Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
What is your postal code?
*
Hidden
What is your postal code? - OLD
Do not enter spaces or dashes.
In what city or town do you live?
*
Are you...
*
Single
Living with spouse/partner
Married
Divorced
Widowed
Do you identify as…
*
Straight
Lesbian
Gay
Bisexual
Transgender
Queer or Questioning
No comment
Do any of the following types of people live in your household?
*
Children 5 years of age or younger
Children 6-12
Children 13-17
Children 18 or older
Enrolled in or planning to take college or other courses
Homeschooled children
In the military
Military Veteran
Twins
Elderly parents(s)
Caregiver to patient or elder
Physically handicapped
Obese or very overweight
Native Spanish speaker
Dogs (some of us think they're people!)
Cats (ditto)
Farmer/rancher
Cigarette smoker/ tobacco user
Marijuana user
Super techie
None of these
(Select all that apply)
Something else very unique:
Do you or do others living in your household suffer from any of the following conditions?
*
Addison's disease
Addiction (drug, gambling, alcohol, etc.)
Age-related macular degeneration (AMD)
ALS (Lou Gehrig's Disease)
Alzheimer's Disease and other Dementias
Arthritis
Asthma
Bipolar Mood Disorder
Blindness
Brain trauma/Head injury
Bronchiectasis
Cancer
Cardiac failure
Cardiomyopathy
Chronic Obstructive Pulmonary Disease (COPD)
Chronic fatigue
Chronic pain
Chronic renal disease
Coronary artery disease
Crohn's disease
Cystic Fibrosis
Deafness
Diabetes – Type 1
Diabetes – Type 2
Depression
Dysrhythmias
Erectile Dysfunction (ED)
Epilepsy/Seizures
Glaucoma
Hemophilia
Heartburn or GERD
Herpes
Hepatitis-C
High blood pressure (Hypertension)
High cholesterol
HIV or AIDS
HPV (human papillomavirus)
Hyperlipidemia
Hypothyroidism
Lupus
Migraines - ongoing
Missing limbs
Multiple sclerosis
Neuropathy
Panic or Anxiety Disorder
Paralysis
Parkinson's
Peyronies
Periodontal (or gum disease)
Restless leg syndrome
Schizophrenia
Sleep Disorder
Stroke
Ulcerative colitis
None of these
Rare or Orphan Disease or Other Item Not Listed:
What is your highest level of education obtained?
*
Less than 8th grade
Less than high school but past 8th grade
High school or GED
Trade or Tech School
Some college but no degree
Associates
Bachelors
Masters
JD or PhD
Please select which of these best describes your type of employment
*
Entry level
Experienced
Manager (one location)
Manager (multiple locations)
Upper Management: VP/Director
C-Level (CEO/CXO)
Medical professional (MD, DO, DDS, nurse, etc.)
Laborer
Tradesperson (electrician, hairdresser, baker, mechanic, etc.)
Small business owner
Franchise owner
Franchise employee
Stay at home parent
Retired
Unemployed
Other:
Which of these best describes the industry in which you work?
*
Agricultural
Construction
Government
Education
Financial
Health care and social assistance
Information services
Leisure and hospitality
Manufacturing
Mining
Professional or business services
Retail
Wholesale
Utilities
Transportation & warehousing
Other:
Please tell us your job title and briefly what you do:
*
If you have a LinkedIn Profile, please enter it below to be considered for executive or business studies or press next to skip. You may cut and paste. Note all LI addresses start with https://www.linkedin.com/in/
What is your approximate annual total household income?
*
Under $15,000
$15,000 - $24,999
$25,000 - $34,999
$35,000 - $49,999
$50,000 - $74,999
$75,000 - $99,999
$100,000 - $149,999
$150,000 - $199,999
$200,000+
Refuse (FYI: many studies require a specific income range. Choosing refuse may disqualify you from a number of studies.)
Do you…
*
Own your own home
Rent / Other
What type of structure do you live in?
*
Single-family home
Building with 2 to 4 units
Building with 5 or more units
Mobile home
Other
And a few final fun questions….
Do any of these “stereotypes” describe you?! You can choose up to five if the shoe fits!
Artist
Beer Connoisseur
Biker – into motorcycles
Bookworm – enjoys cracking open a book to take an adventure or acquire knowledge
Churchgoer – goes to church regularly and participates in things at church
Citygirl/boy – little knowledge or desire for the country way of life, probably never baited a fish hook or stepped in a cow patty
Countrygirl/guy – minds your manners, strong-willed, honest, fends for self and family
Crafty – loves to work hands-on to create, build, and fix things
DIYer – one who avidly practices the art of DIY!
Foodie – constantly seek out new, fun and exciting eating & dining experiences
Gambler – wages on most everything
Gamer – never lagging to sign in and conquers some “noobs”
Good Samaritan – someone who volunteers their time & helps others
Hipster – non-mainstream, counter-culture, independent
Ink Addict – loves tattoos and craves more of them
Jane or Jack-of-all-traits – can pretty much handle anything that needs to be done w/out calling for help
JetSetter – have a ton of airline miles & travel wherever you want around the world
Musician – plays a musical instrument frequently and loves doing it and/or performing
Outdoorsy – likes to spend any free time enjoying the outdoors
Politico – obsessed with politics
Pothead – one who believes any activity is more enjoyable whilst stoned
Prepper – prepared for various worst-case scenarios
Shopaholic – always willing to take part in a sale whether online or in store
SoccerMom – you know the definition!
Sports Fanatic – watches all the games, wears all the colors
Traveler – frequent explorer of new surroundings
Weekend warrior – pretty much works during the week, but brings out all the toys for the weekend, bicycling, boating, paddle boarding
Wine Connoisseur
Workaholic – life is mostly much work, eat, sleep, repeat (and you probably love doing it)
None of these
I’m really more like this:
And a few final fun questions….
Have you been or do you/are you…. Please choose all that apply
Bit by a brown recluse spider
Hit by lightening
Make your own wine or beer
Have extreme fear of the dentist
Trader (you love trading the market!)
Wrongly-accused of a crime
A near-death experience
Misdiagnosed
Addicted to prescription drugs
Had shingles
Had your identity stolen
Experienced love at first sight
None of these
How would you describe yourself on the political spectrum?
Values
Spectrum: Generally speaking, social conservatives generally want the preservation of traditional values. Social liberals generally believe people have the right to do what they please so long as it’s not hurting anyone else.
Politics
Spectrum: Generally speaking, the left believe that all people have equal rights, equal obligations, and believe in absence of class and of discrimination. The right leaning generally believe in preserving traditional social and hierarchal institutions that help provide stability & continuity like religion and traditional economics.
