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First name
Last name
Email
Password
Gender
Phone
Age
Race/Ethnicity
Religion
Highest Education Level
Household Income
For whom are you most concerned about a medical illness? Select all that apply
Myself
Spouse
Mother
Father
Child
Other relative
Friend
No one in particular
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What types of illness is affecting you or your loved one? Select all that apply.
Aging
Alzheimer Disease
Arthritis
Blood disorder
Cancer
Congenital (at birth) medical problem
Diabetes
Dementia
Gastrointestinal Disease
Genetic Disorder
Heart Disease
Kidney Disease/Renal Disease
Liver Disease/Hepatitis
Lung Disease/Pulmonary Disease
Osteoporosis/Bone Disease
Psychiatric Problem/Depression/Schizophrenia
Seizures/Epilepsy
Stroke
Other
If Other, please specify:
What are you most worried about?
What is the biggest trouble you find with doctors?
What is the biggest trouble you find with the medical system?
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