www.surveymonkey.com
Open in
urlscan Pro
54.192.146.44
Public Scan
URL:
https://www.surveymonkey.com/r/MHNPANELS2021
Submission: On September 16 via manual from US — Scanned from DE
Submission: On September 16 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
Name: surveyForm — POST
<form name="surveyForm" action="" method="post" enctype="multipart/form-data" novalidate="" data-survey-page-form="">
<div class="questions clearfix">
<div class="question-row clearfix
">
<div data-question-type="demographic_us" data-rq-question-type="contact" class="question-container
">
<div id="question-field-646105655" data-qnumber="1" data-qdispnumber="1" data-question-id="646105655" class=" question-demographic question-demographic-us qn question us question-required">
<h3 class="screenreader-only">Question Title</h3>
<div class="text-input-group question-fieldset question-legend">
<h4 id="question-title-646105655" class=" question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 1<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> Murray Hill National, a market research company, will be in your area soon conducting PAID RESEARCH. We would like to invite you to receive notifications on all studies that might apply to you. All of our <br>research
will pay you an incentive. Cash and / or Rewards. We will input your information into our <br>database and contact you if you meet specific criteria. To get started, we require, at a minimum,<br> your contact
information. We are asking a host of questions that will assist us in narrowing down which <br>studies / research best meets your profile. We are excited to work with you.</span>
</h4>
<div class="question-body clearfix notranslate ">
<div class="text-input-container clearfix">
<label for="646105655_4244995643" class="question-body-font-theme answer-label question-demographic-label user-generated " style="width:20%;"> Name: * </label><input id="646105655_4244995643" name="646105655_4244995643" type="text"
class="text medium" size="30" aria-required="true" data-sm-open-single="">
</div>
<div class="text-input-container clearfix">
<label for="646105655_4244995644" class="question-body-font-theme answer-label question-demographic-label user-generated " style="width:20%;"> Company: </label><input id="646105655_4244995644" name="646105655_4244995644" type="text"
class="text medium" size="30" data-sm-open-single="">
</div>
<div class="text-input-container clearfix">
<label for="646105655_4244995645" class="question-body-font-theme answer-label question-demographic-label user-generated " style="width:20%;"> Address: </label><input id="646105655_4244995645" name="646105655_4244995645" type="text"
class="text medium" size="30" data-sm-open-single="">
</div>
<div class="text-input-container clearfix">
<label for="646105655_4244995646" class="question-body-font-theme answer-label question-demographic-label user-generated " style="width:20%;"> Address 2: </label><input id="646105655_4244995646" name="646105655_4244995646" type="text"
class="text medium" size="30" data-sm-open-single="">
</div>
<div class="text-input-container clearfix">
<label for="646105655_4244995647" class="question-body-font-theme answer-label question-demographic-label user-generated " style="width:20%;"> City/Town: </label><input id="646105655_4244995647" name="646105655_4244995647" type="text"
class="text medium" size="15" data-sm-open-single="">
</div>
<div class="text-input-container clearfix">
<label for="646105655_4244995648" class="question-body-font-theme answer-label question-demographic-label user-generated " style="width:20%;"> State: </label><select id="646105655_4244995648" class="select"
name="646105655_4244995648">
<option value="">-- select state --</option>
<option value="AL">AL Alabama</option>
<option value="AK">AK Alaska</option>
<option value="AS">AS American Samoa</option>
<option value="AZ">AZ Arizona</option>
<option value="AR">AR Arkansas</option>
<option value="CA">CA California</option>
<option value="CO">CO Colorado</option>
<option value="CT">CT Connecticut</option>
<option value="DE">DE Delaware</option>
<option value="DC">DC District of Columbia</option>
<option value="FM">FM Federated States of Micronesia</option>
<option value="FL">FL Florida</option>
<option value="GA">GA Georgia</option>
<option value="GU">GU Guam</option>
<option value="HI">HI Hawaii</option>
<option value="ID">ID Idaho</option>
<option value="IL">IL Illinois</option>
<option value="IN">IN Indiana</option>
<option value="IA">IA Iowa</option>
<option value="KS">KS Kansas</option>
<option value="KY">KY Kentucky</option>
<option value="LA">LA Louisiana</option>
<option value="ME">ME Maine</option>
<option value="MH">MH Marshall Islands</option>
<option value="MD">MD Maryland</option>
<option value="MA">MA Massachusetts</option>
<option value="MI">MI Michigan</option>
<option value="MN">MN Minnesota</option>
<option value="MS">MS Mississippi</option>
<option value="MO">MO Missouri</option>
<option value="MT">MT Montana</option>
<option value="NE">NE Nebraska</option>
<option value="NV">NV Nevada</option>
<option value="NH">NH New Hampshire</option>
<option value="NJ">NJ New Jersey</option>
<option value="NM">NM New Mexico</option>
<option value="NY">NY New York</option>
<option value="NC">NC North Carolina</option>
<option value="ND">ND North Dakota</option>
<option value="MP">MP Northern Mariana Islands</option>
<option value="OH">OH Ohio</option>
<option value="OK">OK Oklahoma</option>
<option value="OR">OR Oregon</option>
<option value="PW">PW Palau</option>
<option value="PA">PA Pennsylvania</option>
<option value="PR">PR Puerto Rico</option>
<option value="RI">RI Rhode Island</option>
<option value="SC">SC South Carolina</option>
<option value="SD">SD South Dakota</option>
<option value="TN">TN Tennessee</option>
<option value="TX">TX Texas</option>
<option value="UT">UT Utah</option>
<option value="VT">VT Vermont</option>
<option value="VI">VI Virgin Islands</option>
<option value="VA">VA Virginia</option>
<option value="WA">WA Washington</option>
<option value="WV">WV West Virginia</option>
<option value="WI">WI Wisconsin</option>
<option value="WY">WY Wyoming</option>
</select>
</div>
<div class="text-input-container clearfix">
<label for="646105655_4244995649" class="question-body-font-theme answer-label question-demographic-label user-generated " style="width:20%;"> ZIP: </label><input id="646105655_4244995649" name="646105655_4244995649" type="text"
class="text medium" size="15" data-sm-open-single="">
</div>
<div class="text-input-container clearfix">
<label for="646105655_4244995650" class="question-body-font-theme answer-label question-demographic-label user-generated " style="width:20%;"> Country: </label><input id="646105655_4244995650" name="646105655_4244995650" type="text"
class="text medium" size="15" data-sm-open-single="">
</div>
<div class="text-input-container clearfix">
<label for="646105655_4244995651" class="question-body-font-theme answer-label question-demographic-label user-generated " style="width:20%;"> Email Address: * </label><input id="646105655_4244995651" name="646105655_4244995651"
type="email" class="text medium" size="30" aria-required="true" data-sm-open-single="">
</div>
<div class="text-input-container clearfix">
<label for="646105655_4244995652" class="question-body-font-theme answer-label question-demographic-label user-generated " style="width:20%;"> Phone Number: * </label><input id="646105655_4244995652" name="646105655_4244995652"
type="tel" class="text medium" size="30" aria-required="true" data-sm-open-single="">
</div>
</div>
</div>
</div>
</div>
</div>
<div class="question-row clearfix
">
<div data-question-type="open_ended_multi" data-rq-question-type="open_ended_multi" class="question-container
">
<div id="question-field-646105675" data-qnumber="2" data-qdispnumber="2" data-question-id="646105675" class=" question-open-ended-multi qn question multi">
<h3 class="screenreader-only">Question Title</h3>
<div class="text-input-group question-fieldset question-legend">
<h4 id="question-title-646105675" class=" question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 2<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> Please tell us about your profession</span>
</h4>
<div class="question-body clearfix notranslate ">
<div class="text-input-container clearfix">
<label class="question-body-font-theme answer-label user-generated " for="646105675_4244996948" style="width:20%;"> Job Title </label><input id="646105675_4244996948" name="646105675_4244996948" type="text" class="text"
size="50" data-sm-open-single="">
</div>
<div class="text-input-container clearfix">
<label class="question-body-font-theme answer-label user-generated " for="646105675_4244996949" style="width:20%;"> Industry </label><input id="646105675_4244996949" name="646105675_4244996949" type="text" class="text" size="50"
data-sm-open-single="">
</div>
<div class="text-input-container clearfix">
<label class="question-body-font-theme answer-label user-generated " for="646105675_4244996950" style="width:20%;"> Company Name </label><input id="646105675_4244996950" name="646105675_4244996950" type="text" class="text"
size="50" data-sm-open-single="">
</div>
</div>
</div>
</div>
</div>
</div>
<div class="question-row clearfix
">
<div data-question-type="single_choice_vertical" data-rq-question-type="single_choice_vertical" class="question-container
">
<div id="question-field-646105656" data-qnumber="3" data-qdispnumber="3" data-question-id="646105656" class=" question-single-choice-radio qn question vertical">
<h3 class="screenreader-only">Question Title</h3>
<fieldset class=" question-fieldset" data-radio-button-group="">
<legend class="question-legend">
<h4 id="question-title-646105656" class="
question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 3<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> Which category below includes your age?</span>
</h4>
</legend>
<div class="question-body clearfix notranslate ">
<div class="">
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105656">
<input id="646105656_4244995657" aria-labelledby="646105656_4244995657_label" name="646105656" type="radio" role="radio" class="radio-button-input " value="4244995657" aria-checked="false">
<label data-sm-radio-button-label="" id="646105656_4244995657_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105656_4244995657">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> 17 or younger </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105656">
<input id="646105656_4244995658" aria-labelledby="646105656_4244995658_label" name="646105656" type="radio" role="radio" class="radio-button-input " value="4244995658" aria-checked="false">
<label data-sm-radio-button-label="" id="646105656_4244995658_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105656_4244995658">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> 18-20 </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105656">
<input id="646105656_4244995659" aria-labelledby="646105656_4244995659_label" name="646105656" type="radio" role="radio" class="radio-button-input " value="4244995659" aria-checked="false">
<label data-sm-radio-button-label="" id="646105656_4244995659_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105656_4244995659">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> 21-29 </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105656">
<input id="646105656_4244995660" aria-labelledby="646105656_4244995660_label" name="646105656" type="radio" role="radio" class="radio-button-input " value="4244995660" aria-checked="false">
<label data-sm-radio-button-label="" id="646105656_4244995660_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105656_4244995660">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> 30-39 </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105656">
<input id="646105656_4244995661" aria-labelledby="646105656_4244995661_label" name="646105656" type="radio" role="radio" class="radio-button-input " value="4244995661" aria-checked="false">
<label data-sm-radio-button-label="" id="646105656_4244995661_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105656_4244995661">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> 40-49 </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105656">
<input id="646105656_4244995662" aria-labelledby="646105656_4244995662_label" name="646105656" type="radio" role="radio" class="radio-button-input " value="4244995662" aria-checked="false">
<label data-sm-radio-button-label="" id="646105656_4244995662_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105656_4244995662">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> 50-59 </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105656">
<input id="646105656_4244995663" aria-labelledby="646105656_4244995663_label" name="646105656" type="radio" role="radio" class="radio-button-input " value="4244995663" aria-checked="false">
<label data-sm-radio-button-label="" id="646105656_4244995663_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105656_4244995663">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> 60 or older </span>
</label>
</div>
</div>
</div>
</div>
</fieldset>
</div>
</div>
</div>
<div class="question-row clearfix
">
<div data-question-type="single_choice_vertical" data-rq-question-type="single_choice_vertical" class="question-container
">
<div id="question-field-646105657" data-qnumber="4" data-qdispnumber="4" data-question-id="646105657" class=" question-single-choice-radio qn question vertical">
<h3 class="screenreader-only">Question Title</h3>
<fieldset class=" question-fieldset" data-radio-button-group="">
<legend class="question-legend">
<h4 id="question-title-646105657" class="
question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 4<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> What is your gender?</span>
</h4>
</legend>
<div class="question-body clearfix notranslate ">
<div class="">
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105657">
<input id="646105657_4244995664" aria-labelledby="646105657_4244995664_label" name="646105657" type="radio" role="radio" class="radio-button-input " value="4244995664" aria-checked="false">
<label data-sm-radio-button-label="" id="646105657_4244995664_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105657_4244995664">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Female </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105657">
<input id="646105657_4244995665" aria-labelledby="646105657_4244995665_label" name="646105657" type="radio" role="radio" class="radio-button-input " value="4244995665" aria-checked="false">
<label data-sm-radio-button-label="" id="646105657_4244995665_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105657_4244995665">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Male </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105657">
<input id="646105657_4244997127" aria-labelledby="646105657_4244997127_label" name="646105657" type="radio" role="radio" class="radio-button-input " value="4244997127" aria-checked="false">
<label data-sm-radio-button-label="" id="646105657_4244997127_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105657_4244997127">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Other </span>
</label>
</div>
</div>
</div>
</div>
</fieldset>
</div>
</div>
</div>
<div class="question-row clearfix
">
<div data-question-type="single_choice_vertical" data-rq-question-type="single_choice_vertical" class="question-container
">
<div id="question-field-646105658" data-qnumber="5" data-qdispnumber="5" data-question-id="646105658" class=" question-single-choice-radio qn question vertical question-required" style="width:px;
">
<h3 class="screenreader-only">Question Title</h3>
<fieldset class=" question-fieldset" data-radio-button-group="">
<legend class="question-legend">
<h4 id="question-title-646105658" class="
question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 5<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> What is your ethnicity? </span>
</h4>
</legend>
<div class="question-body clearfix notranslate ">
<div class="">
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105658">
<input id="646105658_4244995672" aria-labelledby="646105658_4244995672_label" name="646105658" type="radio" role="radio" class="radio-button-input " value="4244995672" aria-checked="false">
<label data-sm-radio-button-label="" id="646105658_4244995672_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105658_4244995672">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Caucasian </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105658">
<input id="646105658_4244995673" aria-labelledby="646105658_4244995673_label" name="646105658" type="radio" role="radio" class="radio-button-input " value="4244995673" aria-checked="false">
<label data-sm-radio-button-label="" id="646105658_4244995673_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105658_4244995673">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> African American / Black </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105658">
<input id="646105658_4244995674" aria-labelledby="646105658_4244995674_label" name="646105658" type="radio" role="radio" class="radio-button-input " value="4244995674" aria-checked="false">
<label data-sm-radio-button-label="" id="646105658_4244995674_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105658_4244995674">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Asian </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105658">
<input id="646105658_4244995675" aria-labelledby="646105658_4244995675_label" name="646105658" type="radio" role="radio" class="radio-button-input " value="4244995675" aria-checked="false">
<label data-sm-radio-button-label="" id="646105658_4244995675_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105658_4244995675">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> American Indian / Native American </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105658">
<input id="646105658_4244995676" aria-labelledby="646105658_4244995676_label" name="646105658" type="radio" role="radio" class="radio-button-input " value="4244995676" aria-checked="false">
<label data-sm-radio-button-label="" id="646105658_4244995676_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105658_4244995676">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Hispanic / Latino </span>
</label>
</div>
</div>
</div>
<div class="other-answer-container other-answer-option-container">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105658">
<input id="646105658_4244995669" aria-labelledby="646105658_4244995669_label" name="646105658" type="radio" role="radio" class="radio-button-input " value="4244995669" aria-checked="false" data-other-answer="">
<label data-sm-radio-button-label="" id="646105658_4244995669_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105658_4244995669">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Other (please specify) </span>
</label>
</div>
<input id="646105658_other" name="646105658_other" type="text" class="text other-answer-text" size="50" aria-label="Other (please specify)" data-other-text="">
</div>
</div>
</fieldset>
</div>
</div>
</div>
<div class="question-row clearfix
">
<div data-question-type="single_choice_vertical" data-rq-question-type="single_choice_vertical" class="question-container
">
<div id="question-field-646105659" data-qnumber="6" data-qdispnumber="6" data-question-id="646105659" class=" question-single-choice-radio qn question vertical">
<h3 class="screenreader-only">Question Title</h3>
<fieldset class=" question-fieldset" data-radio-button-group="">
<legend class="question-legend">
<h4 id="question-title-646105659" class="
question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 6<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> What is your approximate average household income?</span>
</h4>
</legend>
<div class="question-body clearfix notranslate ">
<div class="">
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105659">
<input id="646105659_4244995677" aria-labelledby="646105659_4244995677_label" name="646105659" type="radio" role="radio" class="radio-button-input " value="4244995677" aria-checked="false">
<label data-sm-radio-button-label="" id="646105659_4244995677_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105659_4244995677">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> $0-$24,999 </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105659">
<input id="646105659_4244995678" aria-labelledby="646105659_4244995678_label" name="646105659" type="radio" role="radio" class="radio-button-input " value="4244995678" aria-checked="false">
<label data-sm-radio-button-label="" id="646105659_4244995678_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105659_4244995678">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> $25,000-$49,999 </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105659">
<input id="646105659_4244995679" aria-labelledby="646105659_4244995679_label" name="646105659" type="radio" role="radio" class="radio-button-input " value="4244995679" aria-checked="false">
<label data-sm-radio-button-label="" id="646105659_4244995679_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105659_4244995679">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> $50,000-$74,999 </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105659">
<input id="646105659_4244995680" aria-labelledby="646105659_4244995680_label" name="646105659" type="radio" role="radio" class="radio-button-input " value="4244995680" aria-checked="false">
<label data-sm-radio-button-label="" id="646105659_4244995680_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105659_4244995680">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> $75,000-$99,999 </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105659">
<input id="646105659_4244995681" aria-labelledby="646105659_4244995681_label" name="646105659" type="radio" role="radio" class="radio-button-input " value="4244995681" aria-checked="false">
<label data-sm-radio-button-label="" id="646105659_4244995681_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105659_4244995681">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> $100,000-$124,999 </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105659">
<input id="646105659_4244995682" aria-labelledby="646105659_4244995682_label" name="646105659" type="radio" role="radio" class="radio-button-input " value="4244995682" aria-checked="false">
<label data-sm-radio-button-label="" id="646105659_4244995682_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105659_4244995682">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> $125,000-$149,999 </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105659">
<input id="646105659_4244995683" aria-labelledby="646105659_4244995683_label" name="646105659" type="radio" role="radio" class="radio-button-input " value="4244995683" aria-checked="false">
<label data-sm-radio-button-label="" id="646105659_4244995683_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105659_4244995683">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> $150,000-$174,999 </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105659">
<input id="646105659_4244995684" aria-labelledby="646105659_4244995684_label" name="646105659" type="radio" role="radio" class="radio-button-input " value="4244995684" aria-checked="false">
<label data-sm-radio-button-label="" id="646105659_4244995684_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105659_4244995684">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> $175,000-$199,999 </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105659">
<input id="646105659_4244995685" aria-labelledby="646105659_4244995685_label" name="646105659" type="radio" role="radio" class="radio-button-input " value="4244995685" aria-checked="false">
<label data-sm-radio-button-label="" id="646105659_4244995685_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105659_4244995685">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> $200,000 and up </span>
</label>
</div>
</div>
</div>
</div>
</fieldset>
</div>
</div>
</div>
<div class="question-row clearfix
">
<div data-question-type="single_choice_vertical" data-rq-question-type="single_choice_vertical" class="question-container
">
<div id="question-field-646105671" data-qnumber="7" data-qdispnumber="7" data-question-id="646105671" class=" question-single-choice-radio qn question vertical">
<h3 class="screenreader-only">Question Title</h3>
<fieldset class=" question-fieldset" data-radio-button-group="">
<legend class="question-legend">
<h4 id="question-title-646105671" class="
question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 7<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> Which of the following best describes your health insurance coverage?</span>
</h4>
</legend>
<div class="question-body clearfix notranslate ">
<div class="">
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105671">
<input id="646105671_4244995787" aria-labelledby="646105671_4244995787_label" name="646105671" type="radio" role="radio" class="radio-button-input " value="4244995787" aria-checked="false">
<label data-sm-radio-button-label="" id="646105671_4244995787_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105671_4244995787">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Group Health Insurance (through your or your family member's employer) </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105671">
<input id="646105671_4244995788" aria-labelledby="646105671_4244995788_label" name="646105671" type="radio" role="radio" class="radio-button-input " value="4244995788" aria-checked="false">
<label data-sm-radio-button-label="" id="646105671_4244995788_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105671_4244995788">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Individual Health Insurance (that you purchased yourself) </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105671">
<input id="646105671_4244995789" aria-labelledby="646105671_4244995789_label" name="646105671" type="radio" role="radio" class="radio-button-input " value="4244995789" aria-checked="false">
<label data-sm-radio-button-label="" id="646105671_4244995789_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105671_4244995789">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Medicare / Enrolling in Medicare </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105671">
<input id="646105671_4244995790" aria-labelledby="646105671_4244995790_label" name="646105671" type="radio" role="radio" class="radio-button-input " value="4244995790" aria-checked="false">
<label data-sm-radio-button-label="" id="646105671_4244995790_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105671_4244995790">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Medicaid </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105671">
<input id="646105671_4244995791" aria-labelledby="646105671_4244995791_label" name="646105671" type="radio" role="radio" class="radio-button-input " value="4244995791" aria-checked="false">
<label data-sm-radio-button-label="" id="646105671_4244995791_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105671_4244995791">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> No Health Insurance </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105671">
<input id="646105671_4244995792" aria-labelledby="646105671_4244995792_label" name="646105671" type="radio" role="radio" class="radio-button-input " value="4244995792" aria-checked="false">
<label data-sm-radio-button-label="" id="646105671_4244995792_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105671_4244995792">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Military, VA or Federal Employee </span>
</label>
</div>
</div>
</div>
</div>
</fieldset>
</div>
</div>
</div>
<div class="question-row clearfix
">
<div data-question-type="multiple_choice_vertical_three_col" data-rq-question-type="multiple_choice_vertical_three_col" class="question-container
">
<div id="question-field-646105661" data-qnumber="8" data-qdispnumber="8" data-question-id="646105661" class=" question-multiple-choice qn question vertical_three_col">
<h3 class="screenreader-only">Question Title</h3>
<fieldset class=" question-fieldset">
<legend class="question-legend">
<h4 id="question-title-646105661" class="
question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 8<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> Please pick all that apply</span>
</h4>
</legend>
<div class="question-body clearfix notranslate ">
<div class="answer-option-col
answer-option-col-3">
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="646105661_4244995686" name="646105661[]" type="checkbox" class="checkbox-button-input " value="4244995686">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="646105661_4244995686">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Have children under 18 </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="646105661_4244995814" name="646105661[]" type="checkbox" class="checkbox-button-input " value="4244995814">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="646105661_4244995814">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Have children under 5 </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="646105661_4244995687" name="646105661[]" type="checkbox" class="checkbox-button-input " value="4244995687">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="646105661_4244995687">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Drink alcoholic beverages </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="646105661_4244995688" name="646105661[]" type="checkbox" class="checkbox-button-input " value="4244995688">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="646105661_4244995688">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Smoke regular cigarettes </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="646105661_4244995689" name="646105661[]" type="checkbox" class="checkbox-button-input " value="4244995689">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="646105661_4244995689">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Smoke menthol cigarettes </span>
</label>
</div>
</div>
</div>
<div class="answer-option-col
answer-option-col-3">
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="646105661_4244997961" name="646105661[]" type="checkbox" class="checkbox-button-input " value="4244997961">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="646105661_4244997961">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Smoke ecigs / Vape </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="646105661_4244995690" name="646105661[]" type="checkbox" class="checkbox-button-input " value="4244995690">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="646105661_4244995690">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Have health insurance I pay for privately </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="646105661_4244995691" name="646105661[]" type="checkbox" class="checkbox-button-input " value="4244995691">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="646105661_4244995691">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Have employer paid health insurance </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="646105661_4244995692" name="646105661[]" type="checkbox" class="checkbox-button-input " value="4244995692">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="646105661_4244995692">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Own home </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="646105661_4244995693" name="646105661[]" type="checkbox" class="checkbox-button-input " value="4244995693">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="646105661_4244995693">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Rent apartment / house / condo </span>
</label>
</div>
</div>
</div>
<div class="answer-option-col
answer-option-col-3">
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="646105661_4244995694" name="646105661[]" type="checkbox" class="checkbox-button-input " value="4244995694">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="646105661_4244995694">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Vote regularly </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="646105661_4244995695" name="646105661[]" type="checkbox" class="checkbox-button-input " value="4244995695">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="646105661_4244995695">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Own a dog or dogs </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="646105661_4244995696" name="646105661[]" type="checkbox" class="checkbox-button-input " value="4244995696">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="646105661_4244995696">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Own a cat or cats </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="646105661_4244997962" name="646105661[]" type="checkbox" class="checkbox-button-input " value="4244997962">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="646105661_4244997962">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Was diagnosed with COVID19 </span>
</label>
</div>
</div>
</div>
</div>
</fieldset>
</div>
</div>
</div>
<div class="question-row clearfix
">
<div data-question-type="matrix_single" data-rq-question-type="single_choice_matrix" class="question-container
">
<div id="question-field-646105662" data-qnumber="9" data-qdispnumber="9" data-question-id="646105662" class=" question-matrix question-matrix-non-accordion qn question single" style="width:px;
">
<h3 class="screenreader-only">Question Title</h3>
<div class=" question-fieldset question-legend">
<h4 id="question-title-646105662" class=" question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 9<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> Please check any of the following that apply to you:</span>
</h4>
<div class="question-body clearfix notranslate ">
<table class="question-matrix-table table-reset reflow" cellspacing="0">
<thead>
<tr>
<td style="width:10%;"> </td>
<td style="width:45.0%;" class="matrix-col-label question-body-font-theme user-generated"> I have been diagnosed with this condition </td>
<td style="width:45.0%;" class="matrix-col-label question-body-font-theme user-generated"> I am a caregiver to a family member or loved on with this condition </td>
</tr>
</thead>
<tbody>
<tr data-radio-button-group="" row="0" class="question-matrix-row-even question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> AFIB </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4244995697_4245005571" aria-labelledby="646105662_4244995697_4245005571_label" name="646105662_4244995697" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4244995697_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4244995697_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">AFIB</span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4244995697_4245005572" aria-labelledby="646105662_4244995697_4245005572_label" name="646105662_4244995697" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4244995697_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4244995697_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">AFIB</span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="1" class="question-matrix-row-odd question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> AIDS / HIV </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245005558_4245005571" aria-labelledby="646105662_4245005558_4245005571_label" name="646105662_4245005558" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245005558_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245005558_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">AIDS / HIV</span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245005558_4245005572" aria-labelledby="646105662_4245005558_4245005572_label" name="646105662_4245005558" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245005558_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245005558_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">AIDS / HIV</span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="2" class="question-matrix-row-even question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> Alopecia </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245005559_4245005571" aria-labelledby="646105662_4245005559_4245005571_label" name="646105662_4245005559" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245005559_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245005559_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Alopecia</span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245005559_4245005572" aria-labelledby="646105662_4245005559_4245005572_label" name="646105662_4245005559" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245005559_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245005559_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Alopecia</span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="3" class="question-matrix-row-odd question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> Alzheimers / Dementia </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245005560_4245005571" aria-labelledby="646105662_4245005560_4245005571_label" name="646105662_4245005560" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245005560_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245005560_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Alzheimers / Dementia </span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245005560_4245005572" aria-labelledby="646105662_4245005560_4245005572_label" name="646105662_4245005560" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245005560_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245005560_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Alzheimers / Dementia </span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="4" class="question-matrix-row-even question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> Ankylosis Spondylitis </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245038200_4245005571" aria-labelledby="646105662_4245038200_4245005571_label" name="646105662_4245038200" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245038200_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245038200_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Ankylosis Spondylitis</span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245038200_4245005572" aria-labelledby="646105662_4245038200_4245005572_label" name="646105662_4245038200" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245038200_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245038200_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Ankylosis Spondylitis</span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="5" class="question-matrix-row-odd question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> Arthritis </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245021961_4245005571" aria-labelledby="646105662_4245021961_4245005571_label" name="646105662_4245021961" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245021961_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245021961_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Arthritis</span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245021961_4245005572" aria-labelledby="646105662_4245021961_4245005572_label" name="646105662_4245021961" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245021961_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245021961_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Arthritis</span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="6" class="question-matrix-row-even question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> Asthma </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245005561_4245005571" aria-labelledby="646105662_4245005561_4245005571_label" name="646105662_4245005561" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245005561_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245005561_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Asthma</span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245005561_4245005572" aria-labelledby="646105662_4245005561_4245005572_label" name="646105662_4245005561" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245005561_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245005561_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Asthma</span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="7" class="question-matrix-row-odd question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> Atopic Dermatitis </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245023775_4245005571" aria-labelledby="646105662_4245023775_4245005571_label" name="646105662_4245023775" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245023775_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245023775_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Atopic Dermatitis</span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245023775_4245005572" aria-labelledby="646105662_4245023775_4245005572_label" name="646105662_4245023775" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245023775_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245023775_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Atopic Dermatitis</span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="8" class="question-matrix-row-even question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> Bladder Condition </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245023776_4245005571" aria-labelledby="646105662_4245023776_4245005571_label" name="646105662_4245023776" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245023776_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245023776_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Bladder Condition</span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245023776_4245005572" aria-labelledby="646105662_4245023776_4245005572_label" name="646105662_4245023776" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245023776_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245023776_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Bladder Condition</span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="9" class="question-matrix-row-odd question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> Cancer </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4244995698_4245005571" aria-labelledby="646105662_4244995698_4245005571_label" name="646105662_4244995698" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4244995698_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4244995698_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Cancer</span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4244995698_4245005572" aria-labelledby="646105662_4244995698_4245005572_label" name="646105662_4244995698" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4244995698_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4244995698_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Cancer</span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="10" class="question-matrix-row-even question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> Cardiomyopathy </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245005562_4245005571" aria-labelledby="646105662_4245005562_4245005571_label" name="646105662_4245005562" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245005562_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245005562_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Cardiomyopathy</span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245005562_4245005572" aria-labelledby="646105662_4245005562_4245005572_label" name="646105662_4245005562" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245005562_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245005562_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Cardiomyopathy</span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="11" class="question-matrix-row-odd question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> Chronic/Congestive Heart Failure Patients </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245005563_4245005571" aria-labelledby="646105662_4245005563_4245005571_label" name="646105662_4245005563" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245005563_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245005563_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Chronic/Congestive Heart Failure Patients</span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245005563_4245005572" aria-labelledby="646105662_4245005563_4245005572_label" name="646105662_4245005563" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245005563_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245005563_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Chronic/Congestive Heart Failure Patients</span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="12" class="question-matrix-row-even question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> Crohn's Disease </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245005564_4245005571" aria-labelledby="646105662_4245005564_4245005571_label" name="646105662_4245005564" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245005564_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245005564_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Crohn's Disease</span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245005564_4245005572" aria-labelledby="646105662_4245005564_4245005572_label" name="646105662_4245005564" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245005564_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245005564_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Crohn's Disease</span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="13" class="question-matrix-row-odd question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> COPD </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4244995699_4245005571" aria-labelledby="646105662_4244995699_4245005571_label" name="646105662_4244995699" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4244995699_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4244995699_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">COPD</span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4244995699_4245005572" aria-labelledby="646105662_4244995699_4245005572_label" name="646105662_4244995699" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4244995699_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4244995699_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">COPD</span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="14" class="question-matrix-row-even question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> COVD19 </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245005565_4245005571" aria-labelledby="646105662_4245005565_4245005571_label" name="646105662_4245005565" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245005565_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245005565_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">COVD19 </span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245005565_4245005572" aria-labelledby="646105662_4245005565_4245005572_label" name="646105662_4245005565" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245005565_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245005565_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">COVD19 </span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="15" class="question-matrix-row-odd question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> Diabetes Type 1 </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4244995700_4245005571" aria-labelledby="646105662_4244995700_4245005571_label" name="646105662_4244995700" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4244995700_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4244995700_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Diabetes Type 1</span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4244995700_4245005572" aria-labelledby="646105662_4244995700_4245005572_label" name="646105662_4244995700" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4244995700_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4244995700_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Diabetes Type 1</span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="16" class="question-matrix-row-even question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> Diabetes Type 2 </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4244995701_4245005571" aria-labelledby="646105662_4244995701_4245005571_label" name="646105662_4244995701" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4244995701_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4244995701_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Diabetes Type 2</span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4244995701_4245005572" aria-labelledby="646105662_4244995701_4245005572_label" name="646105662_4244995701" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4244995701_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4244995701_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Diabetes Type 2</span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="17" class="question-matrix-row-odd question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> Epilepsy </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4244995702_4245005571" aria-labelledby="646105662_4244995702_4245005571_label" name="646105662_4244995702" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4244995702_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4244995702_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Epilepsy</span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4244995702_4245005572" aria-labelledby="646105662_4244995702_4245005572_label" name="646105662_4244995702" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4244995702_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4244995702_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Epilepsy</span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="18" class="question-matrix-row-even question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> Emphysema </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4244995703_4245005571" aria-labelledby="646105662_4244995703_4245005571_label" name="646105662_4244995703" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4244995703_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4244995703_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Emphysema</span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4244995703_4245005572" aria-labelledby="646105662_4244995703_4245005572_label" name="646105662_4244995703" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4244995703_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4244995703_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Emphysema</span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="19" class="question-matrix-row-odd question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> Endometriosis </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245038201_4245005571" aria-labelledby="646105662_4245038201_4245005571_label" name="646105662_4245038201" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245038201_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245038201_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Endometriosis</span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245038201_4245005572" aria-labelledby="646105662_4245038201_4245005572_label" name="646105662_4245038201" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245038201_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245038201_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Endometriosis</span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="20" class="question-matrix-row-even question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> GURD </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245038202_4245005571" aria-labelledby="646105662_4245038202_4245005571_label" name="646105662_4245038202" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245038202_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245038202_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">GURD</span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245038202_4245005572" aria-labelledby="646105662_4245038202_4245005572_label" name="646105662_4245038202" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245038202_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245038202_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">GURD</span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="21" class="question-matrix-row-odd question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> Hemophilia A </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4257915957_4245005571" aria-labelledby="646105662_4257915957_4245005571_label" name="646105662_4257915957" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4257915957_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4257915957_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Hemophilia A </span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4257915957_4245005572" aria-labelledby="646105662_4257915957_4245005572_label" name="646105662_4257915957" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4257915957_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4257915957_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Hemophilia A </span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="22" class="question-matrix-row-even question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> Hemophilia B </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4257915958_4245005571" aria-labelledby="646105662_4257915958_4245005571_label" name="646105662_4257915958" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4257915958_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4257915958_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Hemophilia B </span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4257915958_4245005572" aria-labelledby="646105662_4257915958_4245005572_label" name="646105662_4257915958" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4257915958_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4257915958_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Hemophilia B </span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="23" class="question-matrix-row-odd question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> Hepatitis A </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245005566_4245005571" aria-labelledby="646105662_4245005566_4245005571_label" name="646105662_4245005566" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245005566_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245005566_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Hepatitis A</span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245005566_4245005572" aria-labelledby="646105662_4245005566_4245005572_label" name="646105662_4245005566" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245005566_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245005566_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Hepatitis A</span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="24" class="question-matrix-row-even question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> Hepatitis B </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245005567_4245005571" aria-labelledby="646105662_4245005567_4245005571_label" name="646105662_4245005567" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245005567_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245005567_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Hepatitis B</span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245005567_4245005572" aria-labelledby="646105662_4245005567_4245005572_label" name="646105662_4245005567" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245005567_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245005567_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Hepatitis B</span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="25" class="question-matrix-row-odd question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> Hepatitis C </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245005568_4245005571" aria-labelledby="646105662_4245005568_4245005571_label" name="646105662_4245005568" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245005568_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245005568_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Hepatitis C </span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245005568_4245005572" aria-labelledby="646105662_4245005568_4245005572_label" name="646105662_4245005568" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245005568_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245005568_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Hepatitis C </span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="26" class="question-matrix-row-even question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> High Blood Pressure </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245861222_4245005571" aria-labelledby="646105662_4245861222_4245005571_label" name="646105662_4245861222" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245861222_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245861222_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">High Blood Pressure </span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245861222_4245005572" aria-labelledby="646105662_4245861222_4245005572_label" name="646105662_4245861222" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245861222_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245861222_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">High Blood Pressure </span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="27" class="question-matrix-row-odd question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> High Cholesterol </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245861223_4245005571" aria-labelledby="646105662_4245861223_4245005571_label" name="646105662_4245861223" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245861223_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245861223_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">High Cholesterol</span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245861223_4245005572" aria-labelledby="646105662_4245861223_4245005572_label" name="646105662_4245861223" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245861223_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245861223_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">High Cholesterol</span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="28" class="question-matrix-row-even question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> Hypogonadism </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4244995705_4245005571" aria-labelledby="646105662_4244995705_4245005571_label" name="646105662_4244995705" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4244995705_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4244995705_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Hypogonadism</span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4244995705_4245005572" aria-labelledby="646105662_4244995705_4245005572_label" name="646105662_4244995705" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4244995705_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4244995705_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Hypogonadism</span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="29" class="question-matrix-row-odd question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> Incontinence </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245038203_4245005571" aria-labelledby="646105662_4245038203_4245005571_label" name="646105662_4245038203" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245038203_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245038203_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Incontinence</span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245038203_4245005572" aria-labelledby="646105662_4245038203_4245005572_label" name="646105662_4245038203" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245038203_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245038203_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Incontinence</span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="30" class="question-matrix-row-even question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> Kidney Disease </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245005569_4245005571" aria-labelledby="646105662_4245005569_4245005571_label" name="646105662_4245005569" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245005569_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245005569_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Kidney Disease </span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245005569_4245005572" aria-labelledby="646105662_4245005569_4245005572_label" name="646105662_4245005569" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245005569_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245005569_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Kidney Disease </span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="31" class="question-matrix-row-odd question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> Lupus </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245038204_4245005571" aria-labelledby="646105662_4245038204_4245005571_label" name="646105662_4245038204" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245038204_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245038204_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Lupus</span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245038204_4245005572" aria-labelledby="646105662_4245038204_4245005572_label" name="646105662_4245038204" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245038204_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245038204_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Lupus</span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="32" class="question-matrix-row-even question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> MDD (Major Depression Disorder) </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245861224_4245005571" aria-labelledby="646105662_4245861224_4245005571_label" name="646105662_4245861224" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245861224_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245861224_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">MDD (Major Depression Disorder) </span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245861224_4245005572" aria-labelledby="646105662_4245861224_4245005572_label" name="646105662_4245861224" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245861224_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245861224_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">MDD (Major Depression Disorder) </span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="33" class="question-matrix-row-odd question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> Multiple Sclerosis </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245038205_4245005571" aria-labelledby="646105662_4245038205_4245005571_label" name="646105662_4245038205" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245038205_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245038205_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Multiple Sclerosis</span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245038205_4245005572" aria-labelledby="646105662_4245038205_4245005572_label" name="646105662_4245038205" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245038205_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245038205_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Multiple Sclerosis</span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="34" class="question-matrix-row-even question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> NAFLD ( Non Alcoholic Fatty Liver Disease) </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245023777_4245005571" aria-labelledby="646105662_4245023777_4245005571_label" name="646105662_4245023777" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245023777_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245023777_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">NAFLD ( Non Alcoholic Fatty Liver Disease) </span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245023777_4245005572" aria-labelledby="646105662_4245023777_4245005572_label" name="646105662_4245023777" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245023777_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245023777_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">NAFLD ( Non Alcoholic Fatty Liver Disease) </span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="35" class="question-matrix-row-odd question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> Neutropenia </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245023778_4245005571" aria-labelledby="646105662_4245023778_4245005571_label" name="646105662_4245023778" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245023778_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245023778_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Neutropenia</span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245023778_4245005572" aria-labelledby="646105662_4245023778_4245005572_label" name="646105662_4245023778" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245023778_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245023778_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Neutropenia</span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="36" class="question-matrix-row-even question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> Parkinson's Disease </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4244995811_4245005571" aria-labelledby="646105662_4244995811_4245005571_label" name="646105662_4244995811" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4244995811_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4244995811_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Parkinson's Disease</span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4244995811_4245005572" aria-labelledby="646105662_4244995811_4245005572_label" name="646105662_4244995811" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4244995811_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4244995811_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Parkinson's Disease</span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="37" class="question-matrix-row-odd question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> Plaque Psoriasis (PS) </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245005570_4245005571" aria-labelledby="646105662_4245005570_4245005571_label" name="646105662_4245005570" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245005570_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245005570_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Plaque Psoriasis (PS)</span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245005570_4245005572" aria-labelledby="646105662_4245005570_4245005572_label" name="646105662_4245005570" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245005570_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245005570_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Plaque Psoriasis (PS)</span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="38" class="question-matrix-row-even question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> Rheumatoid Arthritis (RA) </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245021962_4245005571" aria-labelledby="646105662_4245021962_4245005571_label" name="646105662_4245021962" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245021962_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245021962_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Rheumatoid Arthritis (RA)</span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4245021962_4245005572" aria-labelledby="646105662_4245021962_4245005572_label" name="646105662_4245021962" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4245021962_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4245021962_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Rheumatoid Arthritis (RA)</span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="39" class="question-matrix-row-odd question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> Sickle Cell Anemia </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4244995815_4245005571" aria-labelledby="646105662_4244995815_4245005571_label" name="646105662_4244995815" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4244995815_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4244995815_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Sickle Cell Anemia</span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4244995815_4245005572" aria-labelledby="646105662_4244995815_4245005572_label" name="646105662_4244995815" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4244995815_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4244995815_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Sickle Cell Anemia</span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="40" class="question-matrix-row-even question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> Ulcerative Colitis (UC) </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4244995839_4245005571" aria-labelledby="646105662_4244995839_4245005571_label" name="646105662_4244995839" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4244995839_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4244995839_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Ulcerative Colitis (UC)</span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4244995839_4245005572" aria-labelledby="646105662_4244995839_4245005572_label" name="646105662_4244995839" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4244995839_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4244995839_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Ulcerative Colitis (UC)</span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
<tr data-radio-button-group="" row="41" class="question-matrix-row-odd question-matrix-row-last">
<td class="matrix-row-label-cell">
<span class="matrix-row-label question-body-font-theme user-generated"> Uveitis </span>
</td>
<td class="touch-sensitive" col="0">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4244995841_4245005571" aria-labelledby="646105662_4244995841_4245005571_label" name="646105662_4244995841" type="radio" role="radio" class="radio-button-input " value="4245005571" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4244995841_4245005571_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4244995841_4245005571">
<span data-position="0" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Uveitis</span> I have been diagnosed with this condition </span>
</label>
</div>
</td>
<td class="touch-sensitive" col="1">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105662">
<input id="646105662_4244995841_4245005572" aria-labelledby="646105662_4244995841_4245005572_label" name="646105662_4244995841" type="radio" role="radio" class="radio-button-input " value="4245005572" aria-checked="false">
<label data-sm-radio-button-label="" id="646105662_4244995841_4245005572_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105662_4244995841_4245005572">
<span data-position="1" class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated ">
<span class="smusr_radio-row-text">Uveitis</span> I am a caregiver to a family member or loved on with this condition </span>
</label>
</div>
</td>
</tr>
</tbody>
</table>
<div class="other-answer-container">
<label class="question-body-font-theme answer-label other-answer-label comment-label user-generated" for="646105662_other"> Other (please specify) </label>
<input id="646105662_other" name="646105662_other" type="text" class="text other-answer-text" size="50" data-other-text="">
</div>
</div>
</div>
</div>
</div>
</div>
<div class="question-row clearfix
">
<div data-question-type="open_ended_essay" data-rq-question-type="open_ended" class="question-container
">
<div id="question-field-646105672" data-qnumber="10" data-qdispnumber="10" data-question-id="646105672" class=" question-essay qn question essay">
<h3 class="screenreader-only">Question Title</h3>
<div class=" question-fieldset question-legend">
<h4 id="question-title-646105672" class=" question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 10<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> Please list the medications you are currently taking...</span>
</h4>
<div class="question-body clearfix notranslate ">
<div class="textarea-container">
<textarea aria-labelledby="question-title-646105672" id="646105672" name="646105672" class="textarea" spellcheck="true" rows="3" cols="50" data-sm-textarea=""></textarea>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="question-row clearfix
">
<div data-question-type="single_choice_vertical" data-rq-question-type="single_choice_vertical" class="question-container
">
<div id="question-field-646105664" data-qnumber="11" data-qdispnumber="11" data-question-id="646105664" class=" question-single-choice-radio qn question vertical">
<h3 class="screenreader-only">Question Title</h3>
<fieldset class=" question-fieldset" data-radio-button-group="">
<legend class="question-legend">
<h4 id="question-title-646105664" class="
question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 11<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> Do you use Snuff or Snus products?</span>
</h4>
</legend>
<div class="question-body clearfix notranslate ">
<div class="">
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105664">
<input id="646105664_4244995715" aria-labelledby="646105664_4244995715_label" name="646105664" type="radio" role="radio" class="radio-button-input " value="4244995715" aria-checked="false">
<label data-sm-radio-button-label="" id="646105664_4244995715_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105664_4244995715">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Yes </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105664">
<input id="646105664_4244995716" aria-labelledby="646105664_4244995716_label" name="646105664" type="radio" role="radio" class="radio-button-input " value="4244995716" aria-checked="false">
<label data-sm-radio-button-label="" id="646105664_4244995716_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105664_4244995716">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> No </span>
</label>
</div>
</div>
</div>
</div>
</fieldset>
</div>
</div>
</div>
<div class="question-row clearfix
">
<div data-question-type="multiple_choice_vertical" data-rq-question-type="multiple_choice_vertical" class="question-container
">
<div id="question-field-646105665" data-qnumber="12" data-qdispnumber="12" data-question-id="646105665" class=" question-multiple-choice qn question vertical">
<h3 class="screenreader-only">Question Title</h3>
<fieldset class=" question-fieldset">
<legend class="question-legend">
<h4 id="question-title-646105665" class="
question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 12<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> Can you tell me which of the following products you use in your household?</span>
</h4>
</legend>
<div class="question-body clearfix notranslate ">
<div class="">
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="646105665_4244995717" name="646105665[]" type="checkbox" class="checkbox-button-input " value="4244995717">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="646105665_4244995717">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> ATVs </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="646105665_4245010079" name="646105665[]" type="checkbox" class="checkbox-button-input " value="4245010079">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="646105665_4245010079">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Diapers </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="646105665_4244995718" name="646105665[]" type="checkbox" class="checkbox-button-input " value="4244995718">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="646105665_4244995718">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Disposable Training Pants </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="646105665_4244995719" name="646105665[]" type="checkbox" class="checkbox-button-input " value="4244995719">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="646105665_4244995719">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Electric vehicles </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="646105665_4244995720" name="646105665[]" type="checkbox" class="checkbox-button-input " value="4244995720">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="646105665_4244995720">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Incontinence Products </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="646105665_4244995721" name="646105665[]" type="checkbox" class="checkbox-button-input " value="4244995721">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="646105665_4244995721">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Paper Plates </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="646105665_4244995722" name="646105665[]" type="checkbox" class="checkbox-button-input " value="4244995722">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="646105665_4244995722">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Packaged Meat </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="646105665_4244995723" name="646105665[]" type="checkbox" class="checkbox-button-input " value="4244995723">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="646105665_4244995723">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Shampoo and Conditioner </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="646105665_4244995724" name="646105665[]" type="checkbox" class="checkbox-button-input " value="4244995724">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="646105665_4244995724">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Smart Home Devices </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="646105665_4245007383" name="646105665[]" type="checkbox" class="checkbox-button-input " value="4245007383">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="646105665_4245007383">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Soda </span>
</label>
</div>
</div>
</div>
</div>
</fieldset>
</div>
</div>
</div>
<div class="question-row clearfix
">
<div data-question-type="open_ended_multi" data-rq-question-type="open_ended_multi" class="question-container
">
<div id="question-field-646105667" data-qnumber="13" data-qdispnumber="13" data-question-id="646105667" class=" question-open-ended-multi qn question multi">
<h3 class="screenreader-only">Question Title</h3>
<div class="text-input-group question-fieldset question-legend">
<h4 id="question-title-646105667" class=" question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 13<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> Please list the ages of all people living in your household:</span>
</h4>
<div class="question-body clearfix notranslate ">
<div class="text-input-container clearfix">
<label class="question-body-font-theme answer-label user-generated " for="646105667_4244995770" style="width:20%;"> #1: </label><input id="646105667_4244995770" name="646105667_4244995770" type="text" class="text" size="50"
data-sm-open-single="">
</div>
<div class="text-input-container clearfix">
<label class="question-body-font-theme answer-label user-generated " for="646105667_4244995771" style="width:20%;"> #2: </label><input id="646105667_4244995771" name="646105667_4244995771" type="text" class="text" size="50"
data-sm-open-single="">
</div>
<div class="text-input-container clearfix">
<label class="question-body-font-theme answer-label user-generated " for="646105667_4244995772" style="width:20%;"> #3: </label><input id="646105667_4244995772" name="646105667_4244995772" type="text" class="text" size="50"
data-sm-open-single="">
</div>
<div class="text-input-container clearfix">
<label class="question-body-font-theme answer-label user-generated " for="646105667_4244995773" style="width:20%;"> #4: </label><input id="646105667_4244995773" name="646105667_4244995773" type="text" class="text" size="50"
data-sm-open-single="">
</div>
<div class="text-input-container clearfix">
<label class="question-body-font-theme answer-label user-generated " for="646105667_4244995774" style="width:20%;"> #5: </label><input id="646105667_4244995774" name="646105667_4244995774" type="text" class="text" size="50"
data-sm-open-single="">
</div>
</div>
</div>
</div>
</div>
</div>
<div class="question-row clearfix
">
<div data-question-type="single_choice_vertical" data-rq-question-type="single_choice_vertical" class="question-container
">
<div id="question-field-646105677" data-qnumber="14" data-qdispnumber="14" data-question-id="646105677" class=" question-single-choice-radio qn question vertical">
<h3 class="screenreader-only">Question Title</h3>
<fieldset class=" question-fieldset" data-radio-button-group="">
<legend class="question-legend">
<h4 id="question-title-646105677" class="
question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 14<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> We now require proof of diagnosis for all studies related to medical conditions. Are you willing to provide proof of medication and/or a doctor's note?</span>
</h4>
</legend>
<div class="question-body clearfix notranslate ">
<div class="">
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105677">
<input id="646105677_4244995843" aria-labelledby="646105677_4244995843_label" name="646105677" type="radio" role="radio" class="radio-button-input " value="4244995843" aria-checked="false">
<label data-sm-radio-button-label="" id="646105677_4244995843_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105677_4244995843">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Yes </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105677">
<input id="646105677_4244995844" aria-labelledby="646105677_4244995844_label" name="646105677" type="radio" role="radio" class="radio-button-input " value="4244995844" aria-checked="false">
<label data-sm-radio-button-label="" id="646105677_4244995844_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105677_4244995844">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> No </span>
</label>
</div>
</div>
</div>
</div>
</fieldset>
</div>
</div>
</div>
<div class="question-row clearfix
">
<div data-question-type="single_choice_vertical" data-rq-question-type="single_choice_vertical" class="question-container
">
<div id="question-field-646105678" data-qnumber="15" data-qdispnumber="15" data-question-id="646105678" class=" question-single-choice-radio qn question vertical">
<h3 class="screenreader-only">Question Title</h3>
<fieldset class=" question-fieldset" data-radio-button-group="">
<legend class="question-legend">
<h4 id="question-title-646105678" class="
question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 15<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> Do you own an automobile, if so what type</span>
</h4>
</legend>
<div class="question-body clearfix notranslate ">
<div class="">
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105678">
<input id="646105678_4244995845" aria-labelledby="646105678_4244995845_label" name="646105678" type="radio" role="radio" class="radio-button-input " value="4244995845" aria-checked="false">
<label data-sm-radio-button-label="" id="646105678_4244995845_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105678_4244995845">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Truck </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105678">
<input id="646105678_4244995846" aria-labelledby="646105678_4244995846_label" name="646105678" type="radio" role="radio" class="radio-button-input " value="4244995846" aria-checked="false">
<label data-sm-radio-button-label="" id="646105678_4244995846_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105678_4244995846">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> SUV </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105678">
<input id="646105678_4244995847" aria-labelledby="646105678_4244995847_label" name="646105678" type="radio" role="radio" class="radio-button-input " value="4244995847" aria-checked="false">
<label data-sm-radio-button-label="" id="646105678_4244995847_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105678_4244995847">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Sedan </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105678">
<input id="646105678_4244995848" aria-labelledby="646105678_4244995848_label" name="646105678" type="radio" role="radio" class="radio-button-input " value="4244995848" aria-checked="false">
<label data-sm-radio-button-label="" id="646105678_4244995848_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105678_4244995848">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Coupe </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105678">
<input id="646105678_4245008010" aria-labelledby="646105678_4245008010_label" name="646105678" type="radio" role="radio" class="radio-button-input " value="4245008010" aria-checked="false">
<label data-sm-radio-button-label="" id="646105678_4245008010_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105678_4245008010">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Electric vehicle of any body style / type </span>
</label>
</div>
</div>
</div>
</div>
</fieldset>
</div>
</div>
</div>
<div class="question-row clearfix
">
<div data-question-type="single_choice_vertical" data-rq-question-type="single_choice_vertical" class="question-container
">
<div id="question-field-646105679" data-qnumber="16" data-qdispnumber="16" data-question-id="646105679" class=" question-single-choice-radio qn question vertical">
<h3 class="screenreader-only">Question Title</h3>
<fieldset class=" question-fieldset" data-radio-button-group="">
<legend class="question-legend">
<h4 id="question-title-646105679" class="
question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 16<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> Did you purchase your vehicle</span>
</h4>
</legend>
<div class="question-body clearfix notranslate ">
<div class="">
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105679">
<input id="646105679_4244995850" aria-labelledby="646105679_4244995850_label" name="646105679" type="radio" role="radio" class="radio-button-input " value="4244995850" aria-checked="false">
<label data-sm-radio-button-label="" id="646105679_4244995850_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105679_4244995850">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> New </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105679">
<input id="646105679_4244995851" aria-labelledby="646105679_4244995851_label" name="646105679" type="radio" role="radio" class="radio-button-input " value="4244995851" aria-checked="false">
<label data-sm-radio-button-label="" id="646105679_4244995851_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105679_4244995851">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Used </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105679">
<input id="646105679_4244995852" aria-labelledby="646105679_4244995852_label" name="646105679" type="radio" role="radio" class="radio-button-input " value="4244995852" aria-checked="false">
<label data-sm-radio-button-label="" id="646105679_4244995852_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105679_4244995852">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Lease </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646105679">
<input id="646105679_4245008163" aria-labelledby="646105679_4245008163_label" name="646105679" type="radio" role="radio" class="radio-button-input " value="4245008163" aria-checked="false">
<label data-sm-radio-button-label="" id="646105679_4245008163_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646105679_4245008163">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> I do not own / lease a vehicle </span>
</label>
</div>
</div>
</div>
</div>
</fieldset>
</div>
</div>
</div>
<div class="question-row clearfix
">
<div data-question-type="open_ended_multi" data-rq-question-type="open_ended_multi" class="question-container
">
<div id="question-field-646105680" data-qnumber="17" data-qdispnumber="17" data-question-id="646105680" class=" question-open-ended-multi qn question multi">
<h3 class="screenreader-only">Question Title</h3>
<div class="text-input-group question-fieldset question-legend">
<h4 id="question-title-646105680" class=" question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 17<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> Please list all of the vehicles Year, make and model in your household</span>
</h4>
<div class="question-body clearfix notranslate ">
<div class="text-input-container clearfix">
<label class="question-body-font-theme answer-label user-generated " for="646105680_4244995853" style="width:20%;"> Vehicle #1 Year / Make Model </label><input id="646105680_4244995853" name="646105680_4244995853" type="text"
class="text" size="50" data-sm-open-single="">
</div>
<div class="text-input-container clearfix">
<label class="question-body-font-theme answer-label user-generated " for="646105680_4244995854" style="width:20%;"> Vehicle #2 Year / Make Model </label><input id="646105680_4244995854" name="646105680_4244995854" type="text"
class="text" size="50" data-sm-open-single="">
</div>
<div class="text-input-container clearfix">
<label class="question-body-font-theme answer-label user-generated " for="646105680_4244995855" style="width:20%;"> Vehicle #3 Year / Make Model </label><input id="646105680_4244995855" name="646105680_4244995855" type="text"
class="text" size="50" data-sm-open-single="">
</div>
<div class="text-input-container clearfix">
<label class="question-body-font-theme answer-label user-generated " for="646105680_4244995856" style="width:20%;"> Vehicle #4 Year / Make Model </label><input id="646105680_4244995856" name="646105680_4244995856" type="text"
class="text" size="50" data-sm-open-single="">
</div>
</div>
</div>
</div>
</div>
</div>
<div class="question-row clearfix
">
<div data-question-type="single_choice_vertical" data-rq-question-type="single_choice_vertical" class="question-container
">
<div id="question-field-646108575" data-qnumber="18" data-qdispnumber="18" data-question-id="646108575" class=" question-single-choice-radio qn question vertical">
<h3 class="screenreader-only">Question Title</h3>
<fieldset class=" question-fieldset" data-radio-button-group="">
<legend class="question-legend">
<h4 id="question-title-646108575" class="
question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 18<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> We do various types of research and we would like to know which types of projects you might be interested in. Please select all the applicable types of research below that you would be interested in receiving project announcements
about</span>
</h4>
</legend>
<div class="question-body clearfix notranslate ">
<div class="">
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646108575">
<input id="646108575_4245014533" aria-labelledby="646108575_4245014533_label" name="646108575" type="radio" role="radio" class="radio-button-input " value="4245014533" aria-checked="false">
<label data-sm-radio-button-label="" id="646108575_4245014533_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646108575_4245014533">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Consumer Research - This research allows you to share your ideas and feedback about products or services you would buy and use for your self and
your family </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646108575">
<input id="646108575_4245014534" aria-labelledby="646108575_4245014534_label" name="646108575" type="radio" role="radio" class="radio-button-input " value="4245014534" aria-checked="false">
<label data-sm-radio-button-label="" id="646108575_4245014534_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646108575_4245014534">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Patient and Caregiver Medical Research - This research allows patients and caregivers to provide feedback about their experience and issues with
dealing with their conditions </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646108575">
<input id="646108575_4245014535" aria-labelledby="646108575_4245014535_label" name="646108575" type="radio" role="radio" class="radio-button-input " value="4245014535" aria-checked="false">
<label data-sm-radio-button-label="" id="646108575_4245014535_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646108575_4245014535">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Medical Professional Research - This allows persons working in the medical field to provide professional feedback on product and treatment concepts
that are used in the course of your work </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-646108575">
<input id="646108575_4245014536" aria-labelledby="646108575_4245014536_label" name="646108575" type="radio" role="radio" class="radio-button-input " value="4245014536" aria-checked="false">
<label data-sm-radio-button-label="" id="646108575_4245014536_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="646108575_4245014536">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Business Professional Research - This allows business leaders and desk working professionals to provide feedback based on the products
used in your professional day to day activities and / or provide feedback to companies as a business leader on brands or services that are used by your business </span>
</label>
</div>
</div>
</div>
</div>
</fieldset>
</div>
</div>
</div>
</div>
<div class="survey-submit-actions center-text clearfix">
<button type="submit" data-submit-page-button="" class="btn small done-button survey-page-button user-generated notranslate"> Done </button>
</div>
<input type="hidden" id="survey_data" name="survey_data"
value="4FoTYerhlqpl9PSGmuD5IeiKcNhhQwHk5Pd7BhZNYHp8h5dLYtBeJr203BwHVa59v8Yo0yNrdsR0hF0ulhLGHkXjN1wJUE0aRPJwvfS5NLTQ1QMdva38vNCxukfKcRiqGFEdTvW9o8J_2BWzb1lgLd_2F1F1gaDpMgSutAkVY4kEAIUQiFbZoaefuGIFfk_2FXTaywQwUPf_2F68Ei7GWojik5pPbqs3gLDr_2BksxDt6mHNNgudnpu7h5dOMTFk3bsdoijKIpPP9Kw_2Fs54Eupld58Py_2Fcg2oUyA01iaisxitWqfFYhAlW5GguTcSaptnm6K7wfvE7IsteF6iyorts3mLnw2nPdijuZLcTkJlopx07qwAaNVb171ghnPzNm1XuC0rzoHqaEeDPJUvzOtuOoMOsZVODKS8dmOYdLfRB64_2F24vQBkkIr_2F2VaAABFdxzHM3l7PkBhMw0cK_2FSqrgQAmUqnaqK7LfXBba0HjrYrd1Oa1fz45kyjTN0n_2BwBFJn6klZlw93MXvhBB7RcGJZ54rOs4_2FS2zoWzatoRlwxj2ruohWDcEcBRIjkGNxaEH4A1fLcl8hmxE">
<input type="hidden" data-response-quality="" id="response_quality_data" name="response_quality_data" value="{}">
<input type="hidden" id="is_previous" name="is_previous" value="false">
<input type="hidden" id="disable_survey_buttons_on_submit" name="disable_survey_buttons_on_submit" value="">
</form>Text Content
Exit JOIN OUR DATABASE 1. Page1 / 1 100% of survey complete. QUESTION TITLE * 1. MURRAY HILL NATIONAL, A MARKET RESEARCH COMPANY, WILL BE IN YOUR AREA SOON CONDUCTING PAID RESEARCH. WE WOULD LIKE TO INVITE YOU TO RECEIVE NOTIFICATIONS ON ALL STUDIES THAT MIGHT APPLY TO YOU. ALL OF OUR RESEARCH WILL PAY YOU AN INCENTIVE. CASH AND / OR REWARDS. WE WILL INPUT YOUR INFORMATION INTO OUR DATABASE AND CONTACT YOU IF YOU MEET SPECIFIC CRITERIA. TO GET STARTED, WE REQUIRE, AT A MINIMUM, YOUR CONTACT INFORMATION. WE ARE ASKING A HOST OF QUESTIONS THAT WILL ASSIST US IN NARROWING DOWN WHICH STUDIES / RESEARCH BEST MEETS YOUR PROFILE. WE ARE EXCITED TO WORK WITH YOU. Name: * Company: Address: Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Country: Email Address: * Phone Number: * QUESTION TITLE * 2. PLEASE TELL US ABOUT YOUR PROFESSION Job Title Industry Company Name QUESTION TITLE * 3. WHICH CATEGORY BELOW INCLUDES YOUR AGE? 17 or younger 18-20 21-29 30-39 40-49 50-59 60 or older QUESTION TITLE * 4. WHAT IS YOUR GENDER? Female Male Other QUESTION TITLE * 5. WHAT IS YOUR ETHNICITY? Caucasian African American / Black Asian American Indian / Native American Hispanic / Latino Other (please specify) QUESTION TITLE * 6. WHAT IS YOUR APPROXIMATE AVERAGE HOUSEHOLD INCOME? $0-$24,999 $25,000-$49,999 $50,000-$74,999 $75,000-$99,999 $100,000-$124,999 $125,000-$149,999 $150,000-$174,999 $175,000-$199,999 $200,000 and up QUESTION TITLE * 7. WHICH OF THE FOLLOWING BEST DESCRIBES YOUR HEALTH INSURANCE COVERAGE? Group Health Insurance (through your or your family member's employer) Individual Health Insurance (that you purchased yourself) Medicare / Enrolling in Medicare Medicaid No Health Insurance Military, VA or Federal Employee QUESTION TITLE * 8. PLEASE PICK ALL THAT APPLY Have children under 18 Have children under 5 Drink alcoholic beverages Smoke regular cigarettes Smoke menthol cigarettes Smoke ecigs / Vape Have health insurance I pay for privately Have employer paid health insurance Own home Rent apartment / house / condo Vote regularly Own a dog or dogs Own a cat or cats Was diagnosed with COVID19 QUESTION TITLE * 9. PLEASE CHECK ANY OF THE FOLLOWING THAT APPLY TO YOU: I have been diagnosed with this condition I am a caregiver to a family member or loved on with this condition AFIB AFIB I have been diagnosed with this condition AFIB I am a caregiver to a family member or loved on with this condition AIDS / HIV AIDS / HIV I have been diagnosed with this condition AIDS / HIV I am a caregiver to a family member or loved on with this condition Alopecia Alopecia I have been diagnosed with this condition Alopecia I am a caregiver to a family member or loved on with this condition Alzheimers / Dementia Alzheimers / Dementia I have been diagnosed with this condition Alzheimers / Dementia I am a caregiver to a family member or loved on with this condition Ankylosis Spondylitis Ankylosis Spondylitis I have been diagnosed with this condition Ankylosis Spondylitis I am a caregiver to a family member or loved on with this condition Arthritis Arthritis I have been diagnosed with this condition Arthritis I am a caregiver to a family member or loved on with this condition Asthma Asthma I have been diagnosed with this condition Asthma I am a caregiver to a family member or loved on with this condition Atopic Dermatitis Atopic Dermatitis I have been diagnosed with this condition Atopic Dermatitis I am a caregiver to a family member or loved on with this condition Bladder Condition Bladder Condition I have been diagnosed with this condition Bladder Condition I am a caregiver to a family member or loved on with this condition Cancer Cancer I have been diagnosed with this condition Cancer I am a caregiver to a family member or loved on with this condition Cardiomyopathy Cardiomyopathy I have been diagnosed with this condition Cardiomyopathy I am a caregiver to a family member or loved on with this condition Chronic/Congestive Heart Failure Patients Chronic/Congestive Heart Failure Patients I have been diagnosed with this condition Chronic/Congestive Heart Failure Patients I am a caregiver to a family member or loved on with this condition Crohn's Disease Crohn's Disease I have been diagnosed with this condition Crohn's Disease I am a caregiver to a family member or loved on with this condition COPD COPD I have been diagnosed with this condition COPD I am a caregiver to a family member or loved on with this condition COVD19 COVD19 I have been diagnosed with this condition COVD19 I am a caregiver to a family member or loved on with this condition Diabetes Type 1 Diabetes Type 1 I have been diagnosed with this condition Diabetes Type 1 I am a caregiver to a family member or loved on with this condition Diabetes Type 2 Diabetes Type 2 I have been diagnosed with this condition Diabetes Type 2 I am a caregiver to a family member or loved on with this condition Epilepsy Epilepsy I have been diagnosed with this condition Epilepsy I am a caregiver to a family member or loved on with this condition Emphysema Emphysema I have been diagnosed with this condition Emphysema I am a caregiver to a family member or loved on with this condition Endometriosis Endometriosis I have been diagnosed with this condition Endometriosis I am a caregiver to a family member or loved on with this condition GURD GURD I have been diagnosed with this condition GURD I am a caregiver to a family member or loved on with this condition Hemophilia A Hemophilia A I have been diagnosed with this condition Hemophilia A I am a caregiver to a family member or loved on with this condition Hemophilia B Hemophilia B I have been diagnosed with this condition Hemophilia B I am a caregiver to a family member or loved on with this condition Hepatitis A Hepatitis A I have been diagnosed with this condition Hepatitis A I am a caregiver to a family member or loved on with this condition Hepatitis B Hepatitis B I have been diagnosed with this condition Hepatitis B I am a caregiver to a family member or loved on with this condition Hepatitis C Hepatitis C I have been diagnosed with this condition Hepatitis C I am a caregiver to a family member or loved on with this condition High Blood Pressure High Blood Pressure I have been diagnosed with this condition High Blood Pressure I am a caregiver to a family member or loved on with this condition High Cholesterol High Cholesterol I have been diagnosed with this condition High Cholesterol I am a caregiver to a family member or loved on with this condition Hypogonadism Hypogonadism I have been diagnosed with this condition Hypogonadism I am a caregiver to a family member or loved on with this condition Incontinence Incontinence I have been diagnosed with this condition Incontinence I am a caregiver to a family member or loved on with this condition Kidney Disease Kidney Disease I have been diagnosed with this condition Kidney Disease I am a caregiver to a family member or loved on with this condition Lupus Lupus I have been diagnosed with this condition Lupus I am a caregiver to a family member or loved on with this condition MDD (Major Depression Disorder) MDD (Major Depression Disorder) I have been diagnosed with this condition MDD (Major Depression Disorder) I am a caregiver to a family member or loved on with this condition Multiple Sclerosis Multiple Sclerosis I have been diagnosed with this condition Multiple Sclerosis I am a caregiver to a family member or loved on with this condition NAFLD ( Non Alcoholic Fatty Liver Disease) NAFLD ( Non Alcoholic Fatty Liver Disease) I have been diagnosed with this condition NAFLD ( Non Alcoholic Fatty Liver Disease) I am a caregiver to a family member or loved on with this condition Neutropenia Neutropenia I have been diagnosed with this condition Neutropenia I am a caregiver to a family member or loved on with this condition Parkinson's Disease Parkinson's Disease I have been diagnosed with this condition Parkinson's Disease I am a caregiver to a family member or loved on with this condition Plaque Psoriasis (PS) Plaque Psoriasis (PS) I have been diagnosed with this condition Plaque Psoriasis (PS) I am a caregiver to a family member or loved on with this condition Rheumatoid Arthritis (RA) Rheumatoid Arthritis (RA) I have been diagnosed with this condition Rheumatoid Arthritis (RA) I am a caregiver to a family member or loved on with this condition Sickle Cell Anemia Sickle Cell Anemia I have been diagnosed with this condition Sickle Cell Anemia I am a caregiver to a family member or loved on with this condition Ulcerative Colitis (UC) Ulcerative Colitis (UC) I have been diagnosed with this condition Ulcerative Colitis (UC) I am a caregiver to a family member or loved on with this condition Uveitis Uveitis I have been diagnosed with this condition Uveitis I am a caregiver to a family member or loved on with this condition Other (please specify) QUESTION TITLE * 10. PLEASE LIST THE MEDICATIONS YOU ARE CURRENTLY TAKING... QUESTION TITLE * 11. DO YOU USE SNUFF OR SNUS PRODUCTS? Yes No QUESTION TITLE * 12. CAN YOU TELL ME WHICH OF THE FOLLOWING PRODUCTS YOU USE IN YOUR HOUSEHOLD? ATVs Diapers Disposable Training Pants Electric vehicles Incontinence Products Paper Plates Packaged Meat Shampoo and Conditioner Smart Home Devices Soda QUESTION TITLE * 13. PLEASE LIST THE AGES OF ALL PEOPLE LIVING IN YOUR HOUSEHOLD: #1: #2: #3: #4: #5: QUESTION TITLE * 14. WE NOW REQUIRE PROOF OF DIAGNOSIS FOR ALL STUDIES RELATED TO MEDICAL CONDITIONS. ARE YOU WILLING TO PROVIDE PROOF OF MEDICATION AND/OR A DOCTOR'S NOTE? Yes No QUESTION TITLE * 15. DO YOU OWN AN AUTOMOBILE, IF SO WHAT TYPE Truck SUV Sedan Coupe Electric vehicle of any body style / type QUESTION TITLE * 16. DID YOU PURCHASE YOUR VEHICLE New Used Lease I do not own / lease a vehicle QUESTION TITLE * 17. PLEASE LIST ALL OF THE VEHICLES YEAR, MAKE AND MODEL IN YOUR HOUSEHOLD Vehicle #1 Year / Make Model Vehicle #2 Year / Make Model Vehicle #3 Year / Make Model Vehicle #4 Year / Make Model QUESTION TITLE * 18. WE DO VARIOUS TYPES OF RESEARCH AND WE WOULD LIKE TO KNOW WHICH TYPES OF PROJECTS YOU MIGHT BE INTERESTED IN. PLEASE SELECT ALL THE APPLICABLE TYPES OF RESEARCH BELOW THAT YOU WOULD BE INTERESTED IN RECEIVING PROJECT ANNOUNCEMENTS ABOUT Consumer Research - This research allows you to share your ideas and feedback about products or services you would buy and use for your self and your family Patient and Caregiver Medical Research - This research allows patients and caregivers to provide feedback about their experience and issues with dealing with their conditions Medical Professional Research - This allows persons working in the medical field to provide professional feedback on product and treatment concepts that are used in the course of your work Business Professional Research - This allows business leaders and desk working professionals to provide feedback based on the products used in your professional day to day activities and / or provide feedback to companies as a business leader on brands or services that are used by your business Done ( Privacy & Cookie Notice Javascript is required for this site to function, please enable.