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1. Title:* Select Mr. Mrs. Ms. Miss Dr.
2. First Name:*
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1. Check this box if you would like to receive product promotions and the MD Health & Wellness Newsletter, featuring health and wellness information and updates about MD products.
   
   
2. Do you suffer from any of the following?
   (check all that apply)

   1. Joint pain
   2. Occasional heartburn/Acid indigestion
   3. Occasional sleeplessness
   4. Allergies
   5. High cholesterol
   6. Frequent colds

   
   

   Which of the following MD Products have
   you used?

   1. Allergy MD Homeopathic
   2. Cold MD Homeopathic
   3. Sleep MD
   4. Joint MD
   5. Heartburn MD
   6. Cholesterol MD
   7. OmegaSmart MD
   8. None

   
   

   Racial background:

   1. Caucasian
   2. African American
   3. Hispanic
   4. Asian
   5. Other

   
   

   What is the highest education level you
   have completed?

   1. High school
   2. College
   3. University
   4. Graduate school
   5. Post-graduate school

   
   

   What is the range of your annual
   household income?

   1. Less than $24,999
   2. $25,000 – $44,999
   3. $45,000 – $64,999
   4. $65,000 – $89,999
   5. Greater than $90,000

   
   

   Do you have health insurance?

   1. Yes
   2. No

   
   

   Where do you frequently purchase
   your health care products?

   1. Drug store
   2. Health food store
   3. Internet
   4. Supermarket
   5. Mass retailer
   6. Phone/Mail order

   
   

   What do you spend on average per
   month for health care products?

   1. $0
   2. $1 – $49
   3. $50 – $99
   4. Greater than $100

   
   

   Are you the primary decision maker for
   health maintenance in your home?

   1. Yes
   2. No

   
   

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