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HealthCare

Healthcare

First name

Last name

Email

Phone

Address

City

State

Zip Code

Birthday

Occupation

Household Income

Ethnic Background

Marital Status

who is your health insurance provider

Do you have children in the household? if yes, what are their ages

How long have you had you currently Health Insurance provider

How do you obtain your health insurance

Do you have Medicare

Do you have a chronic condition? if so what is/ are the conditions?

What type of Medicare plan do you have ?

When is the last time you went to the ER for your chronic conditon?

Do you have a computer or laptop with a webcam?

Thanks for applying for our research project! We'll get back to you if we can use you for the study!

Superior Recruiting LLC

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