Sign-Up - Consumers

Fields marked with an * are required.

READ BEFORE PROCEEDING: We do require that All Respondents live or work within approximately 50 miles of The Galleria area and you MUST have a working telephone number and a valid email address.

 
Do you live in:
Do we have your permission to contact you regarding upcoming research studies to determine your interest and to see if you fit the criteria required for a specific study?
   

CONTACT INFORMATION

 
   
First Name:*
Last Name:*

Home Phone #:

Work Phone #:
Cell Phone #:
Alt #:
E-Mail address:*
Preferred method of contact:
   

ABOUT YOUR HOME

Home Street Address (Include apt #):

City:

State:

Zip Code:

County:

Type of Dwelling:
Do you currently?
   

ABOUT YOU

Your Employment Status

 

Are you currently?

Your Occupation (current /or most recently held)
Industry You Work In?
Job Title:
Name of your employer?  
Zip Code of your Office:
Your gender?
Date of Birth:
Highest Education Attained
Your Ethnicity or Heritage
Your Marital Status
Your Political Philosophy
Are you registered to vote?
Your Party Affiliation - Voter Registration
   
Statements that Describe May or May Not You  
For each statement, indicate if it describes you a lot, a little, or does not describe you  
   
I would rather hear what others have to say than express my own opinion
I frequently try out new products and services before my friends do
I would make an effort to attend a two-hour discussion to share my thoughts and opinions on topics of interest to me
Asking their customers, like me, is a good way for companies to improve their products and services
   

ABOUT FAMILY MEMBERS LIVING AT HOME

Do you have a Spouse, Significant Other, or other adult living in the household that would also like to become a Research Panelist?

Gender
Date of Birth
2nd Adult Employment Status
2nd Adult Occupation (current or previous)
Industry 2nd Adult Works In
2nd Adult's Name
2nd Adult Job title and employers name:
Zip Code of 2nd Adult’s Office (if applicable):
Highest Education Attained by 2nd Adult
2nd Adult Ethnicity or Heritage
2nd Adult Political Philosophy
2nd Adult are they registered to vote?
2nd Adult Party Affiliation - Voter Registration

2nd Adult Contact Information

 
E-Mail Address:
Work Phone #:
Cell Phone #:

GENDER AND DATE OF BIRTH OF CHILDREN

Do you have children in the household?
Please answer for your oldest Child Under 18, then the next oldest child, etc, we can accept up to 6 children.
Child 1 - Gender
Child 1 - Date of Birth
Child 2 - Gender
Child 2 - Date of Birth
Child 3 - Gender
Child 3 - Date of Birth
Child 4 - Gender
Child 4 - Date of Birth
Child 5 - Gender
Child 5 - Date of Birth
Child 6 - Gender
Child 6 - Date of Birth
   
   
   
   
   

INDIVIDUAL AND FAMILY LIFESTYLE / INTERESTS

Does this describe you or anyone else in your household? Please check all that apply.

 

Smoke Own a pickup truck
Drink Beer Own a luxury foreign brand car, i.e. Lexus, BMW
Drink Wine Own a 2nd home / vacation home
Drink Liquor Own videogame console / gaming devices
Play Lotto/Texas Lottery Own a dog
Eat at fast food restaurants 3+ times per week Own a cat
Attend Church/Synagogue/Services regularly Own a horse
Own an RV (recreational vehicle) Play golf
Own a motorcycle Attend professional sporting events
Own an ATV (all terrain vehicle) Travel by airplane 4+ times per year for business
Own a boat Travel Internationally at least one time per year (any reason)
Own a riding lawnmower  
   

INDIVIDUAL AND FAMILY HOBBIES AND LEISURE ACTIVITIES

Please indicate if any of the following are of interest to you or other family members. Please check all that apply.

 
Arts & Crafts Nightlife/Clubbing
Automotive DIY Outdoor activities
Board Games/Puzzles Shopping
Culinary(cooking, classes) Sports enthusiast
Continuing Education Classes Surfing the web
Cultural interests (theatre, museum, symphony) Reading
Home improvement DIY Travel
Lawn/Garden Video or online gaming
Movies Volunteer/community/church
Music  
   

INDIVIDUAL AND FAMILY MUSIC PREFERENCES

Genres or styles of music you and other family members listen to regularly. Please check all that apply.

 
Christian/Gospel Jazz
Classical Oldies
Contemporary Pop/Top 40
Country/Western Rock/Alternative
Easy Listening R&B
Hip Hop/Rap/Urban Tejano/Salsa/Merengue/Reggaeton
   

INDIVIDUAL AND FAMILY CHRONIC MEDICAL CONDITIONS OR DISEASE

We conduct all manner of different medical research studies, ranging from minor conditions such as allergies up to major conditions such as heart disease or cancer. Do you or any member of your household happen to have any of the following medical conditions or diseases? Please check all that apply.

Cancer
Bone Leukemia
Brain Multiple Myeloma
Breast Lung
Colorectal Lymphoma
Endocrine Eye
Gastrointestinal Skin
Soft Tissue Soft Tissue
Gynecological Urinary System
Head/Neck/Throat Other
   
Heart Disease
High Cholesterol
Hypertension
Previous Heart Attack
Other
   
Respiratory
Allergies
Asthma
COPD
Emphysema
Other
   
Neurological/Mental Health
Addiction Stroke
Alzheimer Migraine/Headaches
Autism Multiple Sclerosis
ADD/ADHD Schizophrenia
Anxiety/Panic Disorder Sleep disorders
Bipolar Shingles
Depression Parkinson's disease
Eating disorders Restless Leg
Epilepsy Other
   
Auto-Immune Diseases
HIV/Aids
Lupus
Fibromyalgia
Other
   
Endocrine
Diabetes Type 1
Diabetes Type 2
Diabetes (type unknown)
   
Gastrointestinal Disorders
Crohn's Disease
IBD
IBS
GERD/Heartburn
Other
   
Arthritis/ Bone / Joint
Osteoarthritis
Rheumatoid Arthritis
Osteoporosis
Other
   
Other
Diseases of the Eye
Skin Disorders
Chronic Pain
Hepatitis
Erectile Dysfunction
Kidney Disease
Genital Herpes
Other
   

HOUSEHOLD INCOME

 

Please select the range that best represents your total household income from last year?

   
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