<% Dim Position, Industry Dim CarMake1 Dim CarMake2 Dim CigaretteBrand, AltCigaretteBrand Dim CigaretteFlavor Dim CigaretteLength, CigaretteType Dim Ethnicity, MaritalStatus, EducationalLevel OpenDatabase() %> Adler-Weiner Research Company - Chicago Qualitative Center
Adler-Weiner Research Company

875 N. Michigan Ave., John Hancock Center, Suite 3260, Chicago, IL 60611
Tel: (312) 944-2555, Fax. (312) 944-7812, Email: info@awres.com
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GENERAL INFO
CONSUMERS
PROFESSIONALS
PHYSICIANS

Physician's Questionnaire

Dear Doctor:

We at Adler-Weiner Research have been asked to speak with consumers and professionals in depth about the products or services that you are using or those products and services that are still under development.  Your opinions are vital to this process and will help us understand how to serve you best. Please take the time to fill out this brief questionnaire; it is for our demographic records ONLY.

Thank you.

IF YOU WOULD LIKE TO UPDATE AN EXISTING PROFILE
PLEASE CALL US AT 847-675-5011
 
GENERAL INFORMATION
* - denotes required fields
*First Name: *Last Name:
*Home # : Work # :
Cell # : Pager # :
Fax # :    
*E-Mail: *Confirmation E-Mail:
*Address: Apt./Suite:
*City: *State:
*Zip:    
   
*Which Location Will You Go To?
PHYSICIAN
Primary Specialty:
Sub Specialty:
Years of Practice:
Medical Practice Status:
Hospital(s)/Clinic(s)
Did you attend medical school in the USA? Yes   No
Are you in a private/solo practice? Yes   No
Are you in a group practice? Yes   No
CARS DRIVEN - please indicate most recent 2 automobiles.
Make: <%=DisplayExcelData("Car Makes", "CarMake1", CarMake1, "", "onChange=""loadList1();""", "Select ...")%> Model: Class: Year:
Make: <%=DisplayExcelData("Car Makes", "CarMake2", CarMake2, "", "onChange=""loadList2();""", "Select ...")%> Model: Class: Year:
Please click Submit only once.

 
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