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* 1. First Name

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* 2. Last Name

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* 3. Email Address

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* 4. Phone Number

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* 5. In what state do you live?

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* 6. What is your zip code?

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* 7. What is your gender?

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* 8. What year were you born?

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* 9. What is the highest level of school you have completed or the highest degree you have received?

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* 10. Which of the following categories best describes your employment status?

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* 11. Do you work in any of the following industries?

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* 12. What is your job title?

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* 13. What is the name of the company you work for?

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* 14. How much total combined money did all members of your HOUSEHOLD earn last year?

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* 15. Are you Mexican, Mexican-American, Chicano, Puerto Rican, Cuban, Cuban-American, or some other Spanish, Hispanic, or Latino group?

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* 16. Are you White, Black or African-American, American Indian or Alaskan Native, Asian, Native Hawaiian or other Pacific islander, or some other race?

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* 17. Which of the following best describes your current relationship status?

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* 18. How many children are you parent or guardian for and live in your household (aged 17 or younger only)?

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* 19. What type of smartphone do you own?

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* 20. Which of the following items do you own?

Tell us a little bit about you:

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* 21. Do you own any pets?

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* 22. Do you rent or own the place you live in?

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* 23. Do you consume any of the following?

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* 24. Do you smoke cigarettes?

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* 25. Do you have any of the following medical conditions?

  Medical Condition Medical Condition Medical Condition Medical Condition
I have this condition
Caregiver of someone with 

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* 26. How did you hear about us?

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* 27. Would you like to be contacted for future (paid) market research opportunites?

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