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	What year were you born?

	What is your zip code?

Are you:

Single

Married

Separated

Widowed

Divorced

Which best describes you?

Employed full-time

Employed part-time

Unemployed

Stay-at-home mom

Student

Retired

	What is the age of your oldest child under 18 living at home?

	What is the gender of your oldest child under 18 living at home?

	What is the age of your second oldest child?

	What is the gender of your second oldest child?

	What is the age of your third oldest child?

	What is the gender of your third oldest child?

	What is the age of your fourth oldest child?

	What is the gender of your fourth oldest child?

	What is the age of your fifth oldest child?

	What is the gender of your fifth oldest child?

Are you pregnant?

Yes

Which of the following types of technology does someone in your household own?

Blue Ray disc player	Digital camcorder
DVD player	DVD recorder
HDTV (High definition TV)	Home theater system
Media center PC	Personal video recorder/Digital video
recorder	Video iPod or MP3 player that plays videos
Video-enabled cell phone	Laptop (PC)
Laptop (Mac)	Netbook
Desktop (PC)	Desktop (Mac)
iPad	Other tablet
Smartphone	Flip phone
None of the above

Which of the following have you bought/booked online in the past 12 months?

Books	Clothes
Dating website membership	Electronics equipment (TV, VCR DVD
player)	Furniture
Games	Hardware
Health and beauty products	Household appliances
Medicine	Music
Secondhand goods	Software
Sports goods	Tickets (cinema, theatre, sports
events)	Videos/DVDs
Other

Which of the following social networks are you a member of?

Classmates.com	Facebook
Flixster	Friendster
Habbo	LinkedIn
MyLife	MySpace
Tagged	Twitter
Window live	YouTube
Other	I am not a member of a social network

How often do you log on to social networks?

Every day or almost every day

Several times a week

Once a week

Several times a month

Less often

Which of the following TV services does your household subscribe to?

Digital cable

Digital cable (With premium channels)

Satellite TV (DirectTV, Dish network)

FIOS TV/Fiber optic TV

Netflix

Hulu

Other

I don’t know

I do not subscribe to any TV services

What is your total household income before taxes?

Less than $10,000

$10,000 to $19,999

$20,000 to $29,999

$30,000 to $39,999

$40,000 to $49,999

$50,000 to $59,999

$60,000 to $69,999

$70,000 to $79,999

$80,000 to $89,999

$90,000 to $99,999

$100,000 to $149,999

$150,000 or more

Which of the following best describes your race/ethnicity?

Caucasian/White

African American/Black

Asian

Latino/Hispanic

Native Hawaiian or other Pacific Islander

American Indian or Alaskan Native

Other

Which of the following conditions, if any, do you have?

Acute pain	ADD/ADHD
Allergies	Breathing/Respiratory conditions
Cancer	Diabetes
Digestive conditions	Eye, ear, nose, throat conditions
Heart/Blood conditions	Immunological conditions
Mental health conditions	Neurological/Brain-related conditions
Pain or Bone/Joint/Muscle conditions	Hair loss
Sexual health	Skin condition
Sleep disorders	Weight condition
Women’s health condition	None of the above

Which of the following conditions, if any, does another member of your household have?

Acute pain	ADD/ADHD
Allergies	Breathing/Respiratory conditions
Cancer	Diabetes
Digestive conditions	Eye, ear, nose, throat conditions
Heart/Blood conditions	Immunological conditions
Men's health conditions	Mental health conditions
Neurological/Brain-related conditions	Pain or Bone/Joint/Muscle conditions
Hair loss	Sexual health
Skin condition	Sleep disorders
Weight condition	Women’s health condition
None of the above

Which of the following medical devices do you, a member of your household, or someone you are a care provider for use?

Blood glucose meter	Braces
Cane	Contact lenses
Crutches	Dentures
Epipen	False teeth
Hearing Aids	Hip replacement
Inhalers	Insulin injections
Mouthguard	Nebulizers
Nicotine gum	Nicotine patches
Oxygen tanks	Pacemakers
Prescription eyeglasses	Prosthetic device
Reading glasses	Retainers
Stent	Walker
Wheelchair	Other medical device
None of the above

Which of the following banks do you have an account with?

I do not have a bank account	Bank of America
Bank of the West	BB&T; Corporation
Capital One	Citigroup (Citibank)
Citizens Bank	Compass Bank
Fifth Third Bank	HSBC
J.P. Morgan Chase	KeyBank
M&T; Bank	PNC Bank
Regions Bank	Sovereign Bank
Sun Trust	TD/Canada
USBank/Firstar	Wells Fargo/Wachovia

Which of the following credit cards do you have?

I do not have a credit card

American Express

Diner’s Club

MasterCard

Visa

Which of the following loans do you have?

I do not have a loan

Automobile Loan

Student Loan

Mortgage

Consumer credit

Which of the following financial assets do you own?

I do not own financial assets

Company profit sharing

Health insurance

Life Insurance

Life insurance invested in stocks

Pension invested in stocks

Pension with guaranteed rate

Real Estate (investment property)

Stocks

Are you the financial decisionmaker in your household?

Yes

I share this responsibility with other(s)

What type of mortgage loans do you currently have?

Adjustable rate mortgage (ARM)

Balloon mortgage

Convertible ARM

Federal Housing administration (FHA) loan

Fixed rate mortgage (FRM)

Interest only mortgage

Veteran’s Administration (VA) loan

Which of the following stocks, bonds or other securities accounts or holdings do you have?

I do not have stocks, bonds or securities	529 College savings plan/registered education savings plan (RESP)
Certificates of deposit (CD)	Corporate and government bonds (taxable)
Employer-sponsored retirement plan with current employer (e.g. 401(k), 403(b))	Employer-sponsored retirement plan with a previous employer (e.g. 401(k), 403(b))
Individual retirement account (IRA)	Municipal bonds (tax free)
Mutual funds	Options and/or derivatives
Real estate investments	Stocks

Approximately how much are your investable assets worth? Please do not include home equity.

I do not have any investable assets
$1-$99,999
$100,000-$249,999
$250,000-$499,999
$500,000-$749,999
$750,000-$999,999
$1,000,000-$1,499,999
$1,500,000-$2,999,999
$3,000,000+

	Do you own or rent your home?

What is your annual household income before taxes?