CompuRx, Inc.

 

Your opinions are important to us!

CompuRx invites you to enroll in the CompuRx Consumer Panel.

From time-to-time, you, as a member of the Panel, will be invited to participate in market research projects. Participation is entirely voluntary and, often times, you will be compensated for the time spent in completing our brief surveys.

To enroll in the CompuRx Consumer Panel, please answer the questions below.

These questions are about your personal characteristics, health and use of certain healthcare services. Please keep in mind that YOUR ANSWERS WILL BE KEPT STRICTLY CONFIDENTIAL and will be used ONLY to solicit your participation in specific market research projects.

 

Email Address: 

USA Panel Enrollment

 
About You:

1. Please indicate your gender:

Male
Female

2. Which of these categories best describes your marital status?

Married
Single, that is, never married
Widowed
Legally separated
Divorced

3. In what year were you born?

 

4. What best describes your occupation?

Business/Professional 
Educator 
Farmer 
Healthcare
Homemaker 
Public Service (Police, Fire, etc.)
Retail Sales
Retired
Skilled Trade (Mechanic, Carpenter, etc.)
Student 
Technology (Computers, Engineering, etc.) 
Unemployed 
Other, please specify:

5. What is your total annual household income before taxes?

Less than $10,000
$10,000 - $24,999
$25,000 - $49,999
$50,000 - $74,999
$75,000 - $99,999
More than $100,000

6. What is the highest level of education you have completed?

Grammar School
Some High School
High School Graduate
Some College
College Graduate
Some Post Graduate
Post Graduate

7. Do you have any children living at home?

Yes
No

8. If 'Yes', what are their age(s)?

Under 6 yrs.
6 - 12 yrs.
13 - 18 yrs.
19 - 21 yrs.
Over 21 yrs.

 
About Your Health:

9. Have you ever been diagnosed by a physician for any of the following conditions? Are you currently taking any type of medication or undergoing treatment for each of the conditions you checked? (MARK ALL THAT APPLY)

 

Medication/Treatment

CANCERS

Diagnosed

Prescription Drug

Herbal Remedy

Other Treatment
Breast
Colon or Rectal
Lung
Ovarian
Prostate
Skin
Other, please specify:

 

Medication/Treatment

CARDIOVASCULAR/CIRCULATORY

Diagnosed

Prescription Drug

Herbal Remedy

Other Treatment
Congestive Heart Failure
Coronary Artery Disease
Hypertension (High Blood Pressure)
Heart Attack (Myocardial Infarction)
Angina/Chest Pain
Stroke
Elevated Cholesterol
Other, please specify:

 

Please press the button below to proceed to the next page of the enrollment process.

 

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