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* Indicates required question
Email
*
Your email
Name (first and last):
*
Your answer
Age:
*
Your answer
Gender
*
Female
Male
Non-binary
Phone Number:
*
Your answer
Which of the following best describes your Ethnicity?
*
White/Caucasian
Black/African American
Hispanic/Latino
Asian or Pacific Islander
Native American/Indigenous
Other:
What is your Highest Level of Education?
*
Some High School
Graduated High School
Some College
Graduated College/technical school
Postgraduate Degree
Are you currently employed? If so, what is your current job title?
*
Your answer
Which of the Following Best Represents your HOUSEHOLD Income?
*
Less than $25k
$25,000-34,999
$35,000-44,999
$45,000-54,999
$55,000-64,999
$65,000 or more
What STATE do you live in?
*
Your answer
What CITY do you live in?
*
Your answer
What COUNTY do you live in?
Your answer
Please tell me to what degree you, yourself, participate in shopping for your own health related products. Would you say you…
Decide what to purchase and make the purchase for yourself
Decide what to buy, but someone else usually purchases for you
Someone else decides what to purchase
Clear selection
Which, if any, of the following conditions have you been diagnosed with?
Hay fever, e.g. allergic rhinitis
Allergies
COPD
Asthma
Diabetes
Hypertension/ High blood pressure
High cholesterol
Cancer
Heart disease
Arthritis
None of these
Do you take medications for any of the above conditions?
Yes
No- I have one or more of the above conditions but I do not currently take any medications to treat them
No- I do NOT have any of the above conditions
Other:
Clear selection
If you currently are treating asthma, Which of the following products, if any, do you use to treat your asthma?
*
Aerospan HFA
Alvesco
ArmonAir RespiClick
Arnuity Ellipta
Asmanex HFA or Asmanex Twisthaler
Flovent Diskus or Flovent HFA
Plumicort Flexhaler
QVAR Flexhaler
Proair HFA
Proair Digihaler
Proair Respiclick
Proventil HFA
Ventolin HFA
Generic albuterol
Xopenex HFA
Generic Levalbuterol
Advair Diskus or Advair HFA
AirDuo RespiClick
Authorized generic of Airduo
Breo Ellipta
Dulera
Symbicort
Wixela Inhub
Option 24
None of the above
Other
Required
How did you hear about this opportunity?
*
Facebook Ads
Posted in a Facebook group I follow
Direct Email from HRS
HRS Website
Other:
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