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Pre-Test Survey - PrimaryOne
Please type the unique identifier from the label here (four digits)
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I. Demographic Information
First Name
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Last Name
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Survey Date
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Street Address
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Address Line 2
City
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State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
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Phone Number
Email Address
Race
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American Indian/Alaskan Native
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
White
Prefer not to answer
Other
Other
Date of Birth
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Ethnicity
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Hispanic or Latino
Not Hispanic or Latino
Prefer not to answer
Gender
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Female
Male
Other (specify)
Other (specify)
Do you consider yourself to be?
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Heterosexual or straight
Homosexual
Bisexual
Prefer not to answer
Primary Language:
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English
Spanish
Other (specify)
Other (specify)
Insurance Information:
Primary Care Physician:
Primary Care Physician Number:
How many people live in your household
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