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Old 03-01-2008, 05:27 PM
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Default $100 Health Issues Study - Atlanta, GA area

Reply to: Atlanta.fieldwork@gmail.com

Study: Health Issues

Date: Wednesday March 5,2008 or Thursday March 6,2008

Incentive: $100.00

Length: 90 minutes

Time: Various times available throughout the day



Name: _____________

Age: ______________

Home Phone: _____________

Wk Phone: ______________

Cell Phone: _____________



Please reply with your answers to the following questions:


Q1. In the past 12 months, have you been suffering from or has a doctor ever told you that you are suffering from any of the following? (Select all that apply)

1 Acid Reflux


2 Allergies


3 Sleep Apnea


4 Narcolepsy


5 Diabetes


6 Sleep Walking


7 Insomnia


8 Migraine Headaches


9 Restless Leg Syndrome

Q.2 Over the past year, did you ever go through a period when you experienced any of the following symptoms? (Please select all that apply)


1 Chest pain of any type including heartburn or indigestion


2 Difficulty breathing while at rest


3 Having difficulty falling asleep


4 Itchy, watery eyes or other allergy-related symptoms


5 Tightness in muscles/joints

6 Waking up frequently during the night with trouble falling back asleep

7 Waking up frequently during the night without trouble falling back asleep

8 Feeling sad or down in the dumps

9 Feeling poorly rested/groggy in the morning/waking up feeling unrefreshed

10 Severe headaches, eye pain or sensitivity to light

11 Unintentionally waking up too early in the morning

12 None of the above


Q3. Do you currently take a prescription medication for any of the following conditions?


1 Indigestion, heartburn or acid reflux


2 Depression

3 Sleep-related symptoms


4 Allergies



5 Migraine headaches


We will only call if you pass the preliminary qualification questions.

Thank you.
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