Thank you for your interest in becoming part of Focuscope's database. Please take a moment to complete the form below.

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General Information
Name   
Street address   
City    County    State    Zip   
Home ph#   ( ) - Work ph #   ( ) -
Cell ph #    ( ) -
Marital status    Gender   
Birth date     
must be 18 years of age or older to register
Race   
Email   
Confirm Email   
Can we contact you for future studies via email?   
Professional Information
Occupation   
ft/pt   
Type of company   

Employer name    

Are you a business owner?

Home based business?
Number of employees: Local    World wide   
Yearly family income   
Are you a business traveler?    How many times a year?   
Spouse occupation     
If you are a student, please enter the name of your school   
Highest level of education completed
Personal Technology Information
Do you have any of the following? (please check all applicable boxes)
Do you own a computer
    
Number of computers at home
Laptop
yes   no
Internet Access 
Cell Phone 
yes   no
If yes, your number
( ) -
Satellite Dish
yes   no
Cable TV
yes   no
High Definition TV
yes   no
Do you have GPS?
yes   no  
Do you own a digital camera?
yes   no  
Vehicle Related Information
Do you own a car?   
1st car
Make
Model
Year
2nd car
Make
Model
Year
Gender & Birth dates of Children Living at Home
(name if you wish to register them)
Child 1
Sex   
Name   
 
Birth date   
Child 2
Sex   
Name   
 
Birth date   
Child 3
Sex   
Name   
 
Birth date   
Child 4
Sex   
Name   
 
Birth date   
Home Ownership Information
Do you:
Own Rent Live with parents
If you own, what type of dwelling do you own?   
General Health Information
Are you pregnant?   
Due date   
Are you diabetic?   
Do you suffer from Irritable Bowel Syndrome?   
Do you have asthma?    
Do you have allergies?   
Do you suffer from arthritis?   
Do you suffer from incontinence?   
Lifestyle Information
Primary language spoken at home
Do you own a pet?
Dog
yes   no
Cat
yes   no  
Other
Please list hobbies
Your Availability
Downtown Chicago
Oak Park
Oakbrook
Detroit
Normal/Bloomington Area
Other

Would you be interested in studies where we come to your home (an in-home study)?

 yes   no
Where Did You Hear About Us?
Please tell us how you heard about us?   
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We respect our respondents' privacy. Accordingly, any personal information you provide to us whether through our website or otherwise, will never be sold to another company.


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Chicago
515 North State Street, Suite 1920
Chicago, IL 60610
312-467-1414

Oak Park
1100 Lake Street, Suite 60
Oak Park, IL 60301
708-386-5086