Health Survey

Take our survey and get up-to-the-minute health news, health information, health offers and more. Stay on top of health trends, receive special offers tailored to your interests and learn about new products and services with Electronic-Confirmation.

 

It's important to supply accurate and complete information. All fields with asterisks are required.

 

First Name: *
Last Name: *
E-mail Address: *
Street Address:
City:
State:
Zip/Postal Code:
Telephone:
Mobile Phone:
Mobile Carrier:
Other Carrier:

 

Demographic Information:

 
Gender:
Date of Birth:
Marital Status:
Income:

 

Health Information

Please indicate below if you suffer from any of the following ailments,or are interested in receiving special offers or information about any of the following (check all that apply)?

ADD/ADHD
Acne
Allergies
Alzheimer's
Anxiety
Arthritis
Asthma
Back Pain/Neck Pain
Bladder Control
Bronchitis/Chronic Bronchitis
Cataracts
Chrohn’s Disease
Chronic Pain Sufferers
Depression/Mental health
Diabetes Type I
Diabetes Type II
Dry Eyes
Eczema
GERD/ Reflux
Glaucoma
Heart Disease
Heartburn/Acid Indigestion
High Blood Pressure
High Cholesterol
Insomnia/Sleep Disorder
Irritable Bowel Syndrome (IBS)
Menopause
Migraines/Headaches
Obesity/Weight Control
Osteoarthritis
Osteoporosis
Psoriasis
Rheumatism/Rheumatoid Arthritis
Ulcerative Colitis
 

I would like to receive additional information from third party advertisers related to my above health conditions.
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