Email Address *First Name *Last Name *Phone Number *Where do you currently live? *State/Province *ZIP / Postal Code *Country *AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre & MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabweBirth Date *What is your ethnicity? Select all that apply *- Select -Black or African AmericanAsian or Pacific IslanderAmerican Indian, Alaskan Native, or IndigenousMiddle EasternAsian Indian or Eastern IndianOtherWhat is your gender *- Select -MaleFemalePrefer to Self DescribeOtherAre you a member of the LGBTQIA+ community? *- Select -YesNoNot Comfortable DisclosingWhat is your Marital Status? *- Select -Single, Not MarriedIn a Relationship, Not MarriedMarriedSeparated or DivorcedWidowedDo you have children under 18? *- Select -YesNoWhat type of community do you live in? *- Select -UrbanSuburbanRuralWhat is your current Household Income? *- Select -Less than $20,000 USD$20,001 - $40,000 USD$40,001 - $60,000 USD$60,001 - $80,000 USD$80,001 - $100,000 USD$100,001 - $150,000 USD$150,001 - $200,000 USD$200,001 - $250,000 USD$250,001 USD and aboveWhat is your highest level of education? *- Select -Less than High SchoolHigh School Graduate of GEDSome College2 Year College Graduate or Certification4 Year College GraduatePost-College Graduate Degree - MastersPost-College Graduate Degree - DoctorateOtherWhat is your current employment status? *- Select -Employed - Part TimeEmployed - Full TimeSelf Employed of Independent ContractorStudent OnlyStudent and WorkingStay at Home Parent or HomemakerRetiredOn DisabilityUnemployedOtherSelect all interested study categories.ConsumerBusiness ProfessionalMedical ProfessionalPatient or CaregiverDo you currently own any of the following? *ApparelBeautyElectronicsFurnitureHome AppliancesHomeInsurancePet ProductsPharmacy ItemsVehicleWhat are your hobbies or interests? *Arts and CraftsCollecting MemorabiliaCulinary PursuitsDIY and Home ImprovementGaming and EntertainmentLiterature and WritingMindfulness and WellnessMusic or Performing ArtsNature and GardeningOutdoor ActivitiesSports and FitnessTravel and ExplorationOtherWhat type of home do you currently live in? *- Select -ApartmentCondoDuplexFarmMulti Family HomeSingle Family HomeTownhouseOtherWhat type(s) of vehicle(s) do you currently own? *I do not own any vehicles.CoupeElectric VehicleHatchbackMotorcycleSedanSUVTruckVanOtherWhat type(s) of pet(s) do you currently own? *No petsBirdsCatsDogsFarm AnimalsFishReptilesRodentsOtherWhat type(s) of foods do you typically eat? *Breakfast FoodsCondimentsDessertsFruits or VegetablesPlant-based FoodsSeafoodCanned FoodsDairyFrozen FoodsMeatsPrepared MealsSnacksWhat type(s) of beverages do you typically drink? *Alcoholic BeveragesCoffeeEnergy DrinksJuiceMilkSodaSparkling WaterSports DrinksStill WaterTeaWhat is your primary dietary preference? *- Select -Carnivore - meat onlyHerbivore - plants onlyOmnivore - both animals and plantsPescatarian - plants and fishVegan - plants onlyVegetarian - plantsbut no meatdairy and eggsno animal productsno meatOtherDo you have an food allergies? *- Select -YesNoUnsureDo you have any dietary restrictions? *- Select -YesNoDo you have any other diagnosed health issues? *- Select -YesNoWhat industry do you currently work in? *- Select -AerospaceArchitectureComputerConstruction, Architecture, InspectionElectronics, Non- ComputerEnergyEntertainment, MusicFinance or BusinessGovernment, MilitaryGovernment, Non-MilitaryHealthcareHospitality, Food or BeverageHospitality, OtherManufacturingNews, MediaPharmaceuticalPrimary EducationReal EstateSecondary EducationTele CommunicationTertiary EducationTransportationOtherWhat is your current title or role? *- Select -OwnerCEOCFOCMOCTOPresidentVice PresidentPrincipal or Vice PresidentTeacherDirectorGeneral ManagerManager or SupervisorFull Time EmployeePart Time EmployeeOtherHow many locations does your company have? *- Select -12 - 56 - 1011 - 2526 - 5051 - 100101 and upUnknownHow many employees does your company have? *- Select -1 - 5051 - 100101 - 500501 - 10001001 - 50005001 - 1000010000 and upUnknownWhat is your company's annual revenue in USD? *- Select -Less than $100K USD$100K - $500K USD$500K - $1M USD$1M - $5M USD$5M - $10M USD$10M - $50M USD$50M - $100M USD$100M - $500M USD$500M - $1B USD$1B or moreUnknownWhat is your level of Purchasing Power? *- Select -Yes, I have FULL authority to make purchasing decisions.Somewhat, I have the authority to make decisions with a team or supervisor.No, I do not have the authority to make any purchasing decisions.I am unsure if I have any purchasing decision authority.If/when requested, are you able to provide additional verification? *- Select -Yes, I am willing and able to provide additional verification or credentials if/when needed.No, I am not willing or able to provide additional verification or credentials.What is your current title? *- Select -DentistMedical PhysicianNurse-Practitioner or Advanced PracticeNurse-RN or LPNPharmacist or Pharmacy TechPhysical TherapistPhysician's AssistantRespiratory TherapistSpeech PathologistTechnicianOtherSelect all specialties you practice. *Ambulatory CareCardiacDentalEducatorGeneral or FamilyICUInfusionNeurologyOccupational HealthPICUPreoperativeRadiologySubstance AbuseTransplantWound CareAnesthesiaCase ManagementDermatologyForensicGeriatricInfectious DiseaseNICUNeuroscienceOncologyPain ManagementPsychiatricRehabilitationSurgeryTraumaBurnCritical CareERGastroenterologyHematologyInformaticsNephrologyObstetricsOrthopedicPediatricPublic HealthRheumatologyTelemetryUrologyOtherWhich specialty do you primarily practice? *- Select -Ambulatory CareAnesthesiaBurnCardiacCase ManagementCritical CaseDentalDermatologyERGastroenterologyGeneral or FamilyGeriatricHematologyICUInfectious DiseaseInformaticsInfusionNICUNephrologyNeurologyNeuroscienceObstetricsOccupational HealthOncologyOrthopedicPICUPain ManagementPediatricPreoperativePsychiatricPublic HealthRadiologyRehabilitationRheumatologySubstance AbuseSurgeryTelemetryTransplantTraumaUrologyWound CareOtherHow long have you been practicing? *- Select -Less than 1 year1 - 5 years6 - 10 years11 - 20 years20 or more yearsDo you own your own practice? *- Select -YesNoWhat type is your primary workplace? *- Select -Acute Care HospitalClinicCorrections FacilityHome HealthHospiceLong Term CarePhysician's OfficeSchool or CampTelemedicineUrgent CareWalk-In-ClinicOtherWhat is the urbanicity of your main workplace? *- Select -UrbanSuburbanRuralHow many employees does your company have? *- Select -1 - 1011 - 2526 - 5051 - 100101 - 500501 or moreUnknownDo you work with injections? *- Select -Inject on selfInject on othersInject on self and othersDo not injectIf/when requested, are you able to provide additional verification? *- Select -Yes, I am willing and able to provide additional verification or credentials if/when needed.No, I am not willing or able to provide additional verification or credentials.Select all health conditions that YOU personally have. *No Health ConditionsAlzheimer’s or DementiaArthritis - GoutArthritis - RheumatoidCancer - BladderCancer - BreastCancer - ColorectalCancer - LeukemiaCancer - LungCancer - OtherCancer - PancreaticCancer - SkinCancer - ThyroidChronic Kidney Disease or CKDCoronary Artery Disease or CADDiabetes - PreDiabetes - Type 2Gastrointestinal DisordersHyperlipidemia or High CholesterolHyperthyroidism or HypothyroidismMigraine or Chronic HeadacheObesitySkin Condition - AcneSkin Condition - OtherSleep ApneaAllergic Rhinitis or Hay FeverAnxiety DisordersArthritis - OtherAsthmaCancer - BloodCancer - CervicalCancer - KidneyCancer - LiverCancer - OralCancer - OvarianCancer - ProstateCancer - StomachCancer - UterineChronic Obstructive Pulmonary Disease or COPDDepressionDiabetes - Type 1Gastroesophageal Reflux Disease or GERDHeart AttackHypertension or High Blood PressureMacular DegenerationMultiple SclerosisOsteoporosisSkin Condition - EczemaSkin Condition - PsoriasisStrokeOtherSelect all impairments that YOU personally have. *No ImpairmentsHearing – FullMobility – Short TermNeurologicalVision - FullHearing – PartialLearningMobility – Long TermVision – PartialOtherAre you a Caregiver? *No, I do not care for someone elseYes, I am a caregiver for my spouseYes, I am a caregiver for my child or childrenYes, I am a caregiver for my parentYes, I am a caregiver for someone else outside of my familyYes, I am a caregiver for another family memberDo you work with injections? *- Select -Inject on selfInject on othersInject on self and othersDo not injectTerms and ConditionsIn order to participate in ADR Response Marketing & Research Solutions' market research panel, I hereby attest that I have read and comprehended the terms and conditions stated. 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