Health Survey - Project Kansas

watchLAB welcomes you to the online survey for Project Kansas!

Topic: Health
Incentive: $125
Genders: All genders
Ages: 25-40
Type of study: Focus Group
Length of study: 2 Hours
Dates: Jan. 18-19
Location: San Francisco

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Ready to start the survey?

Contact & Basic Info

First Name

Last Name

Email

Mobile Phone

Gender

City

State

Zip Code

Metro Area

Birthdate (mm/dd/yyyy)

Age

Ethnicity

If "Other" ethnicity, please specify:

What is your...?

Highest level of education attained

Employment Status

In which industry are you employed?

What is your job title and occupation?

What is the name of the company that you work for?

Can you tell me what is your day to day job function entails?

Tell me a bit about yourself. What do you like to do in your spare time? What are some of you hobbies/passions?

Martial Status

Household Income

Family

Do you have any children under 18 living in your home?

How many children do you have under 18 in your home?

First Name (Child 1)

Gender (Child 1)

Date of Birth (Child 1)

First Name (Child 2)

Gender (Child 2)

Date of Birth (Child 2)

First Name (Child 3)

Gender (Child 3)

Date of Birth (Child 3)

Health

How often do you take/use the following over the counter products?

	Never	A few times a year	Few times a month	Multiple times per week	Daily
Aspirin
Ibuprofen
Antacid
Single letter Vitamins (A,C, D etc.)
Multi-Vitamins/mineral supplement
Vitamin Specific supplements (Joint Health, Heart Heath, etc.)
Nasal Spray
Other

Who typically does the shopping in your household when it comes to purchasing health and wellness supplements such as vitamins or minerals?

I doI share the responsibility with someone elseSomeone else does Not sure who does it

Where do you usually purchase vitamins?

Chain pharmacy or drug store (such as CVS, Walgreens etc.)Mass merchandiser (such as Walmart, Target)Warehouse/Club (such as Sam’s, Costco, BJ’s) Grocery store pharmacy (Shoprite) Small independently owned pharmacy Natural health food store or supermarket (e.g., Whole Foods Market) Online Other

You're Almost Done!

Which statement best describes your responsibility for food/shopping/groceries in your household?

I am solely responsibleI have shared responsibility with someone elseI am not responsible at all

How would you describe your role in the kitchen at home when it comes to preparing meals?

I am solely responsibleI have shared responsibility with someone elseI am not responsible at all

How often would you have each of the following items in your shopping basket per month?

Which of the following best describes your interest in food and beverage?

Very InterestedSomewhat InterestedA little interestedNot at all

How often do you read about food?

FrequentlySometimesSeldomNever

When it comes to food and drink, please indicate whether each of the following statements applies to you?

I have a wheat or gluten allergyI have a nut allergyI have strict dietary restrictions for health reasonsI have strict dietary restrictions because of my spiritual beliefs/ religionI have no allergies or dietary restrictions

	4+ times	2-4 times	Once a months	Less than once a month	Never
Fresh Produce
Fresh fish
Fresh poultry
Fresh meat
Almonds
Peanuts
Cashews
Walnuts
Milk
Cheese