How did you hear about us?
Friend
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Fair
Other (fill in below)
(Explain if necessary)
Name
First
Last
Email
Address
Street Address
Apt or number
City
State / Province / Region
Postal / Zip Code
Birth Date
/
MM
/
DD
YYYY
Gender
Male
Female
Home Phone
-
(###)
-
###
####
Work Phone
-
(###)
-
###
####
Cell / Mobile Phone
-
(###)
-
###
####
Do you...
Own home
Rent
Live with family / friends
Total Family Income
Under $20000
$20,000-$29,999
$30,000-$49,999
$50,000-$74,999
$75,000-$100,000
Over $100000
Employment Status
Full time
Part time
Self employed
Homemaker
Unemployed
Marital Status
Single
Married
Divorced
Partnered
Widowed
Occupation
Industry
Highest Education Level Achieved
High School
1 Yr College
2 Yr College
3 Yr College
Vocational Grad
College Grad
Post Grad
Ethnicity
African American
Asian
Caucasian
Hispanic
Indian American
Other
Your Spouse / Partner
Name
First
Last
Email
Birth Date
/
MM
/
DD
YYYY
Gender
Male
Female
Home Phone
-
(###)
-
###
####
Work Phone
-
(###)
-
###
####
Cell / Mobile Phone
-
(###)
-
###
####
Employment Status
Full time
Part time
Self employed
Homemaker
Unemployed
Occupation
Industry
Highest Education Level Achieved
High School
1 Yr College
2 Yr College
3 Yr College
Vocational Grad
College Grad
Post Grad
Ethnicity
African American
Asian
Caucasian
Hispanic
Indian American
Other
Children under 18 that live with you
Birth Date
/
MM
/
DD
YYYY
Gender
Male
Female
Birth Date
/
MM
/
DD
YYYY
Gender
Male
Female
Date
/
MM
/
DD
YYYY
Gender
Male
Female
Birth Date
/
MM
/
DD
YYYY
Gender
Male
Female
Birth Date
/
MM
/
DD
YYYY
Gender
Male
Female
Profile
Do you belong to a health club?
Yes
No
When you vote do you vote ...
Democratic
Republican
Independent
Other
Unregistered
What type of music do you listen to?
Alternative
Blues / Jazz
Rock
Light Rock
Classical
Country
Religious
Public
News / Talk
Sports
Oldies
What health issues do you or someone in your household have?
Juvenile Diabetes
Diabetes Type I
Diabetes Type II
High Blood Pressure
High Cholesterol
Heart Disease
Depression
Skin Condition
ADD/ADHD
Autism
Seasonal Allergies
Migraines
Cystic Fibrosis
Celiac Disease
Lupus
Multiple Sclerosis
Incontinence
Parkinson's
Lactose Intolerant
Cancer
Epilepsy
Hepatitis
Discount store memberships (check all)?
Sam's Club
CostCo
Other
None
What is your primary grocery store type?
National/Regional (Cub, Rainbow, Lunds/Byerlys)
National/Regional Superstore (SuperTarget or Wal-Mart)
Natural (Trader Joe's / Whole Foods)
Do you purchase organic on a regular basis?
Yes
No
Which high end appliances do you own (check all)?
High End Kitchen
High End Laundry
None
Which recreational activities do you participate in (check all)?
ATV
Boating
Downhill Skiing / Snowboarding
Jet Skiing
Fishing
Gardening
Golfing
Hunting
RV/Camping
Snowmobiling
Water Skiing