Topic: XYZ Company
Questions: 25
Income For Completing Survey: $35

First Name

Last Name

Mailing Address

City, State, Zip

Email Address

1. Sex?
Male
Female

2. What Is Your Age Range?
18-24
25-31
32-40
41or Older

3. Where Do You Receive Your Prescriptions At?
Wal-Mart
Kmart
Walgreens
CVS Pharmacy
Eckert
Rite-Aid
Medicap
Other (specify)

4. How Often Do You Refill Your Prescription?
12 Times A Year
6 times A Year
3 times a Year
Once Or Twice A Year
Hardly Ever

5. On average, how much money do you spend on Prescription Drugs Each Month
under $60
$60 to $120
$120 to $180
$180 to $250
More? List Amount
 

6. Are Online Pharmacies Available In Your Area?
Yes
No
No Clue

7. Do You Have An Insurance Provider
Yes
No
If So List Here

8. When Picking Up your Prescription You?
Buy Only Your Prescription
Grocery Shop As Well
Shop With Coupons That Have Been Made Available

9. Have You Ever Shopped For Your Prescription Online?
Yes
No

10. How Often Do You Shop Online For Prescriptions?
Once A Month
Once Every 3 Months
Twice A Year
Yearly

11. How would you rate the customer service at the Pharmacy You Usually Go To?
Poor
Average
Very Good
Excellent

12. Which Grocery Store Do you Normally Shop At?
Wal Mart
Kroeger
Kmart
Safeway
Albertsons
Other (specify)

13. How often do you shop for Groceries month?
5 times a month
4 times a month
3 times a month
twice a month
once a month
less often than once month

14. On average, how much money do you spend on grocery stores?
under $75
$76 to $125
$126 to $200
$201 to $275
$276 to $350
$351 to $450
$451 or more

15. Are online pharmacy/drugstore services available in your area?
Yes
No
Don't know

16. Have you ever shopped online for pharmacy/drugstore products?
Yes
No

17. When you purchase groceries you...?
Purchase additional items that you see advertised
Buy Only What You Came For
Browse around and buy what you want

18. Have you ever used coupons for groceries
Yes
No

19. Does the grocery store offer a preferred buyers program
Yes
No

20. How would you rate the grocery store's customer service that you normally shop at?
Very Good
Good
Bad
Very Bad

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