Medical Conditions Study

4.Culver’s

Medical Conditions

First name

Last name

Address

City

State

Zip code

What county do you live in?

Phone

Occupation

What company do you work for?

Birthday required

If you have kids what are their ages/ gender

When was the last time, if ever, you participated in a market research study – including but not limited to a taste test, home use test, discussion group, online discussion or individual interview? Required

Never

3 months

6 + months or more

What was/were the topic(s) of discussion in this/these group(s)?

What type of health insurance coverage do you currently have?

What provider or insurance company is your current plans coverage through?

Have you been diagnosed by a physician with any type of medical conditions?

What current prescriptions if any are you taking for your diagnosed condition?

, please describe a recent experience where you felt really satisfied—or dissatisfied—with a service you received (it does not need to be healthcare related). What stood out to you?

Thanks for applying for our research project! We'll get back to you if we can use you for the study!