MEDICAL SERVICES USED AT HOSPITAL OR OTHER MEDICAL FACILITY PAST 3 YEARS*

• Any Overnight Stay Procedure
• Cancer/Oncology
• Cardiac Care
• Corrective Eye Surgery
• Cosmetic Surgery
• Maternity Care
• Mental Healthcare
• Neurology
• Non-Surgical Cosmetic Dentistry (Teeth Whitening, Veneers, etc.)
• Orthopedics
• Pediatrics
• Reconstructive Surgery
• Other Medical Services

HEALTHCARE SPECIALISTS USED PAST 12 MONTHS

• Cardiologist
• Chiropractor
• Dentist
• Dermatologist (Skin Doctor)
• Fee-Paid Weight Loss Program
• Ophthalmologist (Eye Doctor)
• Optometrist (Eye Examiner)
• Plastic/Cosmetic Surgeon
• Podiatrist (Foot Doctor)
• Other Specialist

STORES BOUGHT GLASSES/CONTACT LENSES PAST 12 MONTHS

HOUSEHOLD MEMBERS WHO WEAR GLASSES OR CONTACT LENSES*

HOSPITALS USED PAST 3 YEARS*

PHARMACEUTICALS

• Places Purchased Prescription Drugs/Non-Prescription Drugs/Health/Beauty Items Past 30 Days

REASONS BOUGHT MEDICATIONS (OTC/RX) PAST 12 MONTHS

• Allergies
• Arthritis
• Asthma
• Children's Medicine
• Cholesterol
• Cold or Flu
• Diabetes
• Digestive Disorder
• High Blood Pressure
• Impotence/Erectile Dysfunction (ED)
• Quit Smoking
• Weight Loss
• Other

PLANNING TO SHOP FOR NEXT 12 MONTHS*

• Nursing/Convalescent Services or Retirement Facility

HEALTH INSURANCE

• Type
• Insurance Provider
• — Group
• — Individual

LIFE INSURANCE

BELONG TO A HEALTH/FITNESS CLUB

CONTRIBUTED TO HEALTHCARE/MEDICAL ORGANIZATION*

* Household Measurements