Health
This questionnaire is a pre-screener to seek eligibility for a market research project. You do NOT get compensated for filling out this form. If you pre-qualify, you will receive a text or email from a Recruiter to call our office.  

Online Webcam Group via Desktop/Laptop with Webcam (NO CHROMEBOOK/TABLETS/PHONES)

Thursday February 18th 2021
10:40AM-12:30PM ET, 9:40AM-11:30AM CT, 8:40-10:30AM MT, 7:40-9:30AM PT
12:40-2:30PM ET, 11:40AM-1:30PM CT, 10:40AM-12:30PM MT, 9:40AM-11:30AM PT
3:10-5:00PM ET, 2:10-4:00PM CT, 1:10-3:00PM MT, 12:10-2:00PM PT
5:10-7:00PM ET, 4:10-6:00PM CT, 3:10-5:00PM MT, 2:10-4:00PM PT

Friday February 19th 2021
8:10AM-11:00AM ET, 7:10AM-10:00AM CT, 6:10AM-9:00AM MT, 5:10AM-8:00AM PT
11:10AM-1:00PM ET, 10:10AM-12:00PM CT, 9:10AM-11:00AM MT, 8:10AM-10:00AM PT
1:40-3:30PM ET, 12:40-2:30PM CT, 11:40AM-1:30PM MT, 10:40AM-12:30PM PT
3:40-5:30PM ET, 2:40-4:30PM CT, 1:40-3:30PM MT, 12:40-2:30PM PT

Compensation: $125 (if chosen)

Times are for reference only, booked by available quotas.
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Email *
First Name * *
Last Name *
Your Age * *
Your Age * *
What is your date of Birth? * *
MM
/
DD
/
YYYY
Gender * *
Ethnicity/Race * *
Required
Are you Spanish, Hispanic or Latina/Latina? * *
Email * *
Best Number to Text * *
Cell Phone Carrier * *
Alternate Number
Advanced Opinions communicates via text may we text to communicate with you? * *
Advanced Opinions communicates via email may we email you to communicate with you? * *
State *
The County you Live in (i.e., Lehigh) * *
Your Zip Code where you live * *
The Make/Model of your Cell Phone * *
Are you currently * *
Required
If you are a Student, are you
Clear selection
What is the highest level of education you have completed? * *
If you are currently working, please briefly describe your employment. (IF UNEMPLOYED/HOMEMAKER/RETIRED ENTER PREVIOUS) * If not applicable, enter N/A *
What is your job title? (IF UNEMPLOYED/HOMEMAKER/RETIRED ENTER PREVIOUS) * If not applicable, enter N/A *
What is the name of the company/organization you work for? (IF UNEMPLOYED/HOMEMAKER/RETIRED ENTER PREVIOUS) * If not applicable, enter N/A *
If you are currently working, what industry do you work in? (IF UNEMPLOYED/HOMEMAKER/RETIRED ENTER PREVIOUS) *  If not applicable, enter N/A *
(IF MARRIED OR CO-HABITATING) What is your spouse or partner’s current occupation? What Industry are they currently working in? (IF UNEMPLOYED/HOMEMAKER/RETIRED ENTER PREVIOUS) *Example: FT/Bus Driver/Transportation (If not applicable, enter N/A) *
What best represents your households annual income before taxes? (By this we mean all income brought into the home by all household members) * *
Which of the following best represents your current marital status? * *
Are you a parent/legal guardian.... *
If yes, how old are they? * *
Required
PLEASE SELECT THE FOLLOWING IN YOUR HOUSEHOLD.... * *
Different people sometimes respond in different ways to the same product, and some side effects may not be discovered until many people have used a product over a period of time. For this reason, we are required by law to pass on to our client details of any side effects or product technical complaints related to their own products that are mentioned during the course of market research.Although what you say will, of course, be treated in confidence, should you mention during the discussion a side effect or product technical complaint when you, or someone you know, became ill after taking one of our client’s products, or a problem you have had with one of our client’s products we will need to report this, so that they can learn more about the safety of their products. Are you happy to participate in the interview on this basis? *
T1: Which, if any, of the following technology devices do you currently own and use on a regular basis? *
Required
T2: How comfortable are you using your web browser and trying new capabilities with your computer?   *
T3: Do you have reliable, high-speed internet access at your home/the location you will participate in the research from? *
 T4: Do any of the computers you have access to (at home or work for example) currently run on any of the following operating systems? *
 T5:Would you mind telling me, does the computer that runs Windows XP, Windows 7, Windows 8, or Mac OS X access the Internet using Microsoft Internet Explorer, Mozilla Firefox, Google Chrome, or Apple Safari? *
 T6: Do you have Adobe Flash Player 13.0 or higher currently installed on this computer? *
3. First, do you work or have ever worked in any of the following types of businesses or occupations? *
Required
5. Have you ever participated in a market research study where you’ve been asked to discuss your opinions of products or services before? *
7.     What did you talk about/discuss in that/those research study/studies? *
If not applicable enter NA
8. Thinking about your health, please tell me to what degree you, yourself, are the decision maker for your own health.  Would you say you… *
9.  Please tell me to what degree you personally participate in shopping for your over-the-counter medications. Would you say that you *
10. Please tell me which of these health conditions or illnesses, if any, you have experienced in the past 12 months. *
Did NOT experience past 12mos
Yes, experienced this in past 12mos
GERD
Acid Reflux
Bloating/fullness
Gas
Indigestion
Cold
Seasonal Flu (excluding stomach flu, swine flu, Avian flu or other such flu viruses)
Coronavirus/Covid 19
Heartburn
Upset stomach
11. If you mentioned that you experienced a COLD OR FLU. What symptoms did you experience as a result of that? *
Did not have cold/flu past 12mos
Yes, experienced this symptom from cold past 12mos
Yes, experienced this symptom from flu past 12mos
Yes, experienced this symptom from both cold and flu past 12mos
1. Runny nose
2. Nasal and sinus congestion
3. Sneezing
6. Cough
7. Itchy throat, dry throat
8. Sore throat
9. Hoarseness / loss of voice
11. Sinus inflammation
12. Mucus or congestion in the chest
13. Minor aches and pains
14. High fever [ (103°F and above)]
15. Fever
17.Fatigue, exhaustion, weakness, dizziness
18. Loss of taste or smell
19. Watery eyes
20. Headache
12. If you mention you experience Acid Reflux. Please tell me how often you typically experience these symptoms...Acid Reflux *
12. If you mention you experience Bloating/Fullness. Please tell me how often you typically experience these symptoms...Bloating/Fullness *
12. If you mention you experience Gas. Please tell me how often you typically experience these symptoms...Gas *
12. If you mention you experience Indigestion. Please tell me how often you typically experience these symptoms...Indigestion *
12. If you mention you experience Heartburn. Please tell me how often you typically experience these symptoms...Heartburn *
12. If you mention you experience Upset Stomach. Please tell me how often you typically experience these symptoms...Upset Stomach *
Which of these symptoms you experience most often? *
13A. What did you use to treat your COLD AND/OR FLU, if anything? *
Did not use for cold/flu past 12mos
Did not have cold/flu past 12mos
Yes, used this past 12mos for cold/flu
Sore throat-specific medicines, e.g., sore throat sprays, sore throat syrups
Cough-specific medicines, e.g., cough syrups
Sinus-specific relief (excluding nasal sprays), e.g., decongestants, pressure & pain relief tablets
Nasal sprays and drops
Nasal patches or strips
Cold or Flu multi-symptom relief products (excluding nasal sprays)
Medicated, lozenges, e.g., throat drops, cough drops, soft or hard candies
Pain or fever relievers, e.g., Aspirin, Advil or Tylenol
13B. Please tell me what brand/s have you used in the past 12 months to treat these symptoms? *
Did not use for cold/flu past 12mos
Did not have cold/flu past 12mos
Yes, used this past 12mos for cold/flu
Advil cold/ sinus
Aleve-D sinus/ cold
Alka-Seltzer Plus Cold/Flu
Airborne
Cold-Eeze
Coricidin HBP
DayQuil
Delsym
Emergen-C
Mucinex
NyQuil
Robitussin
Sudafed
Theraflu
Tylenol cold/ sinus
Vicks Sinex
Vicks FluTherapy
Zicam
Store Brand/Private Label (such as CVS brand, Equate, Kirkland, etc.) medicated cold/flu/sinus products
Other medicated cold/flu/sinus products
Aleve Pain Reliever
Tylenol Pain Reliever
Advil Pain Reliever
Excedrin Pain Reliever
Motrin Pain Reliever
Bayer Aspirin
Store Brand Pain Reliever
13C. And, which, if any, of the following brands of cold and flu treatment products would you NOT consider purchasing and/or using in the future? *
Required
13D. If you just mentioned you’ve used Alka-Seltzer Plus in the past 12 months to treat your COLD/FLU SYMPTOMS. Please tell me which specific Alka-Seltzer Plus products you have used in the past 12 months. *
14A. Which brands/forms of over-the-counter medications have you personally purchased and used in the past 12 months to address STOMACH RELATED SYMPTOM(S)? Do you take it once per year, once every few months, once per month, weekly, etc? *
Do not have Stomach Issues
Did not use past 12mos
Once a year
Once every few months
Once per month
Every 2 weeks
Once a week
2-3x/wk
Daily
Alka-Seltzer Effervescent Tablets
Alka-Seltzer Relief Chews
Alka-Seltzer Gummies
Gaviscon
Maalox
Gas-X
Mylanta
Nexium OTC
PepcidAC
Pepto Bismol Liquid
Pepto Bismol Chewable Tablet
Prevacid 24 Hour
Prilosec OTC
Rolaids
Tums
Zantac
Zegerid
Other/Store brand
If you mentioned, other/store brand, what is the specific brand name? *
ie. Up & Up (if not applicable enter NA)
14C And, which, if any, of the following brands would you NOT consider using in the future? *
Required
15. When it comes to decisions about purchasing products to treat COLD AND FLU OR GASTROINSTINAL/STOMACH ISSUES do you…? *
16.  To what extent do you agree or disagree to each of the following statements? *
Strongly Agree
Somewhat Agree
Neither Agree nor Disagree
Somewhat Disagree
Strongly Disagree
I hate to miss out on group events.
My friends would say that I am always unapologetically myself
I believe in strong connections with friends and family.
I enjoy indulgent food occasionally (ice cream Sunday, plate of pasta, etc.
 23. Which of the following statements best describes you in a group situation? *
# of Children in HH under 18? *
  24. Imagine you could throw a party in a post-Covid world. Please tell me what type of party you would throw. Where would it be, what would you celebrate, who would be there? *
What food and/or drinks would you serve? *
What type of music would you play (live band, dj? *
Tell me any details that would make your party a memorable occasion. *
If chosen, the online group platform will require you to be on the phone and in front of your computer using a webcam at the same time. Do you currently have a webcam that you are comfortable using with your computer? *
If chosen, so that we can ensure your computer and webcam work properly with our system and that you’re all set for the actual session, we’ll need to schedule a brief tech-check prior to your live session.  The tech check will consist of logging into a live meeting room, similar to the one for the actual session.You will receive an email 1-2 days prior to your scheduled tech-check.  This email will have instructions for testing your computer, logging into the tech check and logging in for the actual session. You must use a desktop or laptop computer.  You cannot use a tablet, smartphone or any other mobile device.You cannot log in from your car, train, bus etc.You must use the same desktop/laptop computer for your tech check and the actual session.  A wired internet connection is preferred over a wireless internet connection.  If you must use wireless, make sure you are as close to the wireless router as possible.Make sure your computer and phone are fully charged.Make sure you are in a quiet, private room with good lighting and no distractions.  Do not log in from a public place such as a coffee shop, or from work. Do you agree to all these terms? *
If selected, we will need Your Full Legal Name (if a check is issued for participation) *
Full Legal Name
If selected, we will need your Full Address to issue compensation *
Full Address (Example: 123 Main Street, Apt 4B, Anywhere, NV 12345
WHAT IS YOUR LOCAL TIME ZONE? *
Have you been diagnosed by a Medical Physician with GERD to confirm the diagnoses did your Medical Physician confirm a diagnosis of GERD with... *
Required
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