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Attention Allergy, Asthma Sufferers:
We Want to Hear From You!
We are in the process of opening up a new Allergy/Asthma clinic in your area and would like to hear from you on how we can make this center the best it can be to suit your needs.
The survey will take less than 10 minutes to complete.
Your honest and candid feedback is appreciated! (Please note – this survey is best if taken on a computer, iPad or laptop vs. a mobile device)
Thanks for your help!
Research Team
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| * Do you or your children suffer from any of the following? (check all that apply) |
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| * What is your current age? |
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| On a scale of 1 to 7, 1 being the least severe, 7 being the most severe, how would you rate your or your children’s current asthma/allergy/sinus problems?
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| * How are you or your children currently relieving your asthma/allergy/sinus problems? (check all that apply) |
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| * Where do you go to get information about allergies/asthma/sinus problems? (check all that apply) |
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| Please list the exact names of the sources that you use to find information about allergies/asthma/sinus problems in the space provided below. (i.e., webmd.com, achoo allergy magazine, etc.) Please separate each source with a comma (,). | | |
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| * Are you currently seeing any of the following specialists/providers to help you with you or your children’s asthma/allergy/sinus problems? (check all that apply) |
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| Please enter the specialist's name that you are currently seeing, i.e., Dr. Smith, in the space provided below. | | |
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| * How did you hear about the specialist(s) that you are currently seeing? (check all that apply) |
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| * What were the top 2 reasons why you decided to seek out a specialist for your or your children’s allergy/asthma/sinus issues? (please select your top 2 reasons) |
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| * Which of the following factors were important in you choosing a specialist to help with your or your children's allergy/asthma/sinus issues? (check all that apply) |
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| * Do you know what causes your or your children’s allergies/asthma/sinus problems? |
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| On a scale of 1 to 7, 1 being not at all agree and 7 being totally agree how would you rate the following with regards to you or your children’s asthma/allergy/sinus problems?
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| * Are any of the following affecting your ability to receive an accurate diagnosis and/or treatment plan? (check all that apply) |
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| On a scale of 1 to 7, 1 being not at all interested 7 being extremely interested, how would you rate the following statements?
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| Please help us understand your answers to the previous question in the open text box below. (please be specific in telling us why you would or would not be interested in the above) | | |
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| * Are you a parent with children currently living with you in the same household? |
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| Please select which age groups your children fall into. (check all that apply) |
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| * How far away do you live from Richmond, VA? |
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| * What is the highest level of education you received? |
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| * Are you currently working full-time or part-time? (if you have multiple jobs do the hours amount to full-time or part-time) |
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| * What is your approximate household income for this year? |
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