Join Our Online Medical & Dental Panel

From time to time, we will be conducting medical and dental surveys. Those selected to participate will depend upon the particular project. Sometimes we will need to survey people who have a particular condition or set of conditions; sometimes we will need to survey people who do not have particular conditions. If you register to be a panel member and are later invited to participate in an online medical or dental survey, you will receive a minimum incentive of $10.

To join this panel, please identify up to 3 adults (over the age of 18) in your household and answer the following questions. You can enter just your own information if you like. All data will be kept confidential. Please use first names only in the first question.

	Person 1	Person 2	Person 3
First name
Age	18 to 20 21 to 34 35 to 44 45 to 54 55 to 64 65 to 79 80+	18 to 20 21 to 34 35 to 44 45 to 54 55 to 64 65 to 79 80+	18 to 20 21 to 34 35 to 44 45 to 54 55 to 64 65 to 79 80+
Sex	Male Female	Male Female	Male Female
Height	feet inches	feet inches	feet inches
Weight	pounds	pounds	pounds

Conditions present in the past year	Person 1	Person 2	Person 3
Arthritis
Asthma
Colitis
Hair loss
Cataracts
Glaucoma
Macular degeneration
Hypoglycemia
Severe gas/ bloating
Heartburn--acid reflux
Constipation
More than 30 pounds overweight
Gum disease
Other serious dental conditions (e.g., root canal)
Diabetes (Type 1)
Diabetes (Type 2)
Cancer
Heart Disease
Back aches
Shortness of breath
Frequent bouts of diarrhea
Sinus headaches
Migraine headaches
Rheumatism
Allergies
Persistent cough
Flu or Frequent colds
High blood pressure
High cholesterol

Family History	Person 1	Person 2	Person 3
Family history of heart disease?	Yes No	Yes No	Yes No
Family history of cancer?	Yes No	Yes No	Yes No
Family history of diabetes?	Yes No	Yes No	Yes No

Behavior	Person 1	Person 2	Person 3
Does this person smoke?	Yes No	Yes No	Yes No
Does this person drink?	Yes No	Yes No	Yes No
How much does this person exercise in an average week?	Not at all Less than 1 hour 1 hour to less than 2 hours 2 hours to less than 5 hours 5 hours to less than 10 hours 10 hours or more	Not at all Less than 1 hour 1 hour to less than 2 hours 2 hours to less than 5 hours 5 hours to less than 10 hours 10 hours or more	Not at all Less than 1 hour 1 hour to less than 2 hours 2 hours to less than 5 hours 5 hours to less than 10 hours 10 hours or more

Your name
Your email address
Telephone number (optional, but it helps us to reach you in case you change your email address or we want to invite you to participate in a telephone survey)

After you have completed the above questions, please press the submit button below. If we have a study requiring people who have (or don't have) particular medical conditions where we need your input, you may be invited to participate in a survey, in which case you would receive an incentive.

Interested in learning more about The Business Research Lab's Employee Satisfaction Survey Packages? Check out our Gold and Silver Survey Packages.