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 Confidential Health Survey

1. Your year of birth? (Required)    Ex:1951

2. What is your gender? (Required)       1Male        2Female

3. Does anyone in your household currently take any of the following medications?
(Check ALL that apply)

Abilify 214. Diovan 112. Indiplon 208. Patanol 043. Serevent 059.
Accolate 001. Ditropan XL 019. Insulin 032. Paxil 044. Seroquel 215.
Aciphex 002. Effexor 020. Lamisil 033. Penlac 045. Singulair 080.
Actonel 003. Elidel 189. Lantus 077. Pepcid 046. Strattera 188.
Actos 004. Eloxatin 197. Levitra 178. Plavix 047. Spiriva 217.
Adderall XR 190. Emend 194. Lexapro 205. Pravachol 049. Synvisc 061.
Advair 081. Enbrel 180. Lipitor 035. Premarin 050. Tamoxifen 183.
Allegra 005. Entocort 082. Lopressor 211. Prempro 051. Topomax 209.
Ambien 007. Evista 021. Lotrel 103. Prevacid 052. Toprol 212.
Aricept   008. Exelon 022. Lovenox 207. Prilosec Rx 053. Viagra 062.
Arimidex 175. Femara 184. Lunestra 206. Procrit 054. Visudyne 064.
Avandia 009. Flovent 185. Macugen 200. Proscar 056. Vytorin 195.
Bextra 163. Flomax 023. Miacalcin 038. Protonix 213. Wellbutrin XL 181.
Caduet 204. Flonase 024. Nasacort 177. Protopic 187. Xalatan 065.
Celebrex 012. Fosamax 025. Nasalcrom 074. Prozac 057. Xeloda 066.
Celexa 013. Glucophage 026. Nasonex 073. Raptiva 201. Xenical 067.
Cialis 186. Glucotrol 027. Neulasta 152. Relpax 202. Zelnorm 196.
Clarinex 168. Glucovance 028. Neupogen 039. Remicade 075. Zetia 182.
Concerta 191. Humalog 029. Nexium 040. Reminyl 058. Zocor 068.
Coreg 210. Humira 176. Norvasc 076. Requip 216. Zoloft 069.
Cymbalta 199. Humulin 030. Novolin 072. Restasis 192. Zomig 070.
Detrol 018. Imitrex 031. Novolog 198. Ritalin 203. Zyrtec 071.
4. Which of the following OTC pain relievers do you use regularly? (Check ALL that apply)
Aspirin
Motrin
Tylenol
Bayer
Aleve
Excedrin
Advil
Naprosen
Nuprin
5. Do you have prescription drug coverage?       1Yes        2No
6. Are you a "caregiver" or do you oversee or influence the medical decisions of a family member who is chronically ill or disabled?
1Yes        2No
7. Are there any children under 18 years of age presently living in your household?
1Yes        2No
8. Which of the following skin care or hair care products have you or any members of your household purchased? (Check ALL that apply)
Anti-aging cream
Body lotions
Cosmetics/Make-up
Eye cream
Facial cleaners
Facial masque
Hair styling products
Hair coloring products
Moisturizers
Self-tanner/Sun block
Skin firming lotion
Teeth whiteners
9. Does anyone in your household have, or feel at risk, for any of the following conditions? If they have a condition, do they take a prescription drug for it?(Check ALL that apply) (Required)

Have Condition Take Drug For It At Risk Have Condition Take Drug For It At Risk
Aches/Pains 1. 1. 1. Glaucoma 35. 35. 35.
Allergies 3. 3. 3. Headache 36. 36. 36.
Alzheimer's 4. 4. 4. Hearing difficulty 37. 37. 37.
Angina 6. 6. 6. Heart Attack 86. 86. 86.
Anxiety 7. 7. 7. Heartburn 38. 38. 38.
Arthritis/Osteoarthritis 8. 8. 8. High blood pressure 39. 39. 39.
Arthritis/Rheumatoid 9. 9. 9. High cholesterol 40. 40. 40.
Attention deficit disorder 71. 71. 71. Hip Pain/Problems 72. 72. 72.
Asthma 10. 10. 10.Hyperactivity 92. 92. 92.
Backache/pain 2. 2. 2. Irritable bowel syndrome 43. 43. 43.
Bipolar Disorder 104. 104. 104. Lupus 95. 95. 95.
Bladder control 42. 42. 42. Macular degeneration 44. 44. 44.
Breast cancer 12. 12. 12. Memory loss 45. 45. 45.
Chronic bronchitis 14. 14. 14. Menopause 46. 46. 46.
Colorectal Cancer 98. 98. 98. Migraine 47. 47. 47.
Congestive Heart Failure 100. 100. 100. Nail fungus 49. 49. 49.
Constipation 16. 16. 16. Night Sweats/Hot Flashes 99. 99. 99.
COPD 17. 17. 17. OA of the Knee 93. 93. 93.
Coronaty-artery/Heart disease 19. 19. 19. Obesity 50. 50. 50.
Crohn's Disease 69. 69. 69. Osteoposis 51. 51. 51.
Deep Vein Thromposis 70. 70. 70. Overactive Bladder 94. 94. 94.
Depression 20. 20. 20. Parkinson's 53. 53. 53.
Diabetes Type 1 67. 67. 67. Peripheral Arterial Disease 101. 101. 101.
Diabetes Type 2 68. 68. 68. Poor circulation 54. 54. 54.
Diarrhea 22. 22. 22. Prostate problems 55. 55. 55.
Dry eyes 23. 23. 23. Prostate cancer 56. 56. 56.
Dry skin 26. 26. 26. Psoriasis 57. 57. 57.
Eczema 27. 27. 27. Restless Legs Syndrome 102. 102. 102.
Emphysema 28. 28. 28. Sinusitis 60. 60. 60.
Enlarged prostate 29. 29. 29. Skin cancer 97. 97. 97.
Erectile Dysfunction 74. 74. 74. Sleeplessness/Insomnia 61. 61. 61.
Fatigue 30. 30. 30. Snoring