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If you are not already a member of our panel and are interested in joining, complete our questionnaire below.

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* 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?

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?
What is your 5-digit zip code?*
In what Province do you live?
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.

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