HCM Database Form
Fields marked with a red asterisk (
*
) are required.
*
First Name:
*
Last Name:
*
Home Phone:
Work Phone:
Cell Phone:
Email:
Address:
City:
State:
*** Select One ***
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip:
County:
*
Date of Birth:
m/d/yyyy
Gender:
*** Select One ***
Male
Female
Ethnicity:
*** Select One ***
Caucasian
African-American
Hispanic
Asian
Native American
Other
Education:
*** Select One ***
Some High School
High School Grad
Some College/Tech
College Grad
Post Grad
Household Income:
*** Select One ***
Under $20,000
$20-35K
$35-50K
$50-75K
$75-100K
$100-150K
$150K+
Marital Status:
*** Select One ***
Married
Single
Widowed
Divorced
Employment Status:
*** Select One ***
Full-Time
Part-Time
Unemployed
Homemaker
Retired
Student Only
Occupation:
Do you have children living at home under the age of 16?
*** Select One ***
YES
NO
Do you own or rent your primary home?
*** Select One ***
Own
Rent
HCM Research has numerous requests each year to conduct medical research. Please list any health conditions that you have and would be willing to discuss in a focus group setting.