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  1. Name & Address:  
     
    * Title Mr.    Mrs.    Ms.    Miss
    * First Name Initial * Last Name
           
    * Street Apt. No. * City
    * State/Province * Zip/Postal Code
    * E-mail Address
    2.  
  2. Your date of birth:
    3.  
  3. Marital Status: Married Single
    4.  
  4. Date of purchase: 
    5.  
  5. Model number: (located on product)
    6.  
  6. Price paid (excluding sales tax): $ .00
    7.  
  7. Store name:
    8.  
  8. This scale was:
     
    Purchased myself
    Purchased by spouse
    Purchased for business use
    9.  
  9. Please describe this purchase:
     
    A first time purchase
    A replacement of this brand
    A replacement of another brand    		 An additional purchase
    Received as a requested gift
    Received as a surprise gift
    10.  
  10. Please check the three (3) most important factors influencing your purchase?
     
    Healthometer name
    Quality/Durability
    Doctor recommendation
    Style/Appearance
    Accurate reading
    Health problems    		 Value for price
    Compact design
    Replacing old scale
    Dieting
    Warranty
    Easy to read
    11.  
  11. How did you first learn about Healthometer scales?
     
    Newspaper ad
    Magazine ad
    TV/Salesperson
    Mail order catalog
    In-store display
    Friend/Relative
    12.  
  12. Where do you intend to use this scale?
     
    Bathroom
    Exercise room
    Bedroom    		 Kitchen
    At work
    Other
    13.  
  13. Not including yourself, what is the GENDER and AGE (in years) of children and other adults living in your household?
     
    No one else in household Child under 1 year
    1. Male Female Age (in yrs):
    2. Male Female Age (in yrs):
    3. Male Female Age (in yrs):
    4. Male Female Age (in yrs):
    14.  
  14. Occupation: (check all that apply)
     
      You Spouse
    Professional/Technical
    Upper Management/Executive
    Middle Management
    Sales/Marketing
    Clerical/Service Worker
    Tradesman/Machine Operator/Laborer
    15.  
  15. Are you or your spouse:  
     
      You Spouse
    A Homemaker?
    Retired?
    A Student?
    Self Employed/Business Owner?
    Working from a Home Office?
    In the Military?
    A Veteran?
    16.  
  16. Which group describes your annual family income?
     
    Under $15,000
    $15,000-$19,999
    $20,000-$29,999
    $30,000-$39,999
    $40,000-$49,999     		$50,000-$59,999
    $60,000-$74,999
    $75,000-$99,999
    $100,000-$124,999
    $125,000-$149,999     		$150,000-$174,999
    $175,000-$199,999
    $200,000-$249,999
    $250,000 & over
    17.  
  17. Level of education: (select highest level completed)
     
    Completed High School
    Completed College
    Completed Graduate School
    18.  
  18. Which credit cards do you use regularly?
     
    American Express, Diners Club
    MasterCard, Visa, Discover     		Department Store, Oil
          Company, etc.
    Do not use credit cards
    19.  
  19. For your primary residence, do you:
     
    Own? Rent?
    20.  
  20. How recently did you move into your current residence?
     
    Within 30 days
    Within 1-3 months
    Within 4-6 months     		7 to 12 months ago
    Have not moved in the last 12
         months
    21.  
  21. Which of the following do you plan to do within the
    next 1-6 or 7-12 months?     (select all that apply)
     
      1-6 Months 7-12 Months
    Buy/Lease a New Vehicle
    Buy/Lease a Used Vehicle
    22.  
  22. Please check all that apply to your household.
     
    Shop by Catalog/Mail
    Shop via the Internet
    Member of Frequent Flyer
          Program
    Donate to Charitable Causes
    Own a Compact Disc Player
    Have a Dog     		Have a Cat
    Own a Wireless/Cellular Phone
    Speak Spanish
    Own an Apple/Macintosh
          Computer
    Own a CD-ROM Drive
    23.  
  23. To help us understand our customers' lifestyles, please indicate the interests and activities in which you or your spouse enjoy participating on a regular basis.
     
    01. Bicycling
    02. Golf
    03. Physical Fitness/Exercise
    04. Running/Jogging
    05. Snow Skiing
    06. Tennis
    07. Camping/Hiking
    08. Fishing
    09. Hunting/Shooting
    10. Powerboating
    11. Sailing
    12. Grandchildren
    13. Needlework/Knitting
    14. Sewing
    15. Flower Gardening
    16. Vegetable Gardening
    17. Crafts
    18. Buy Prerecorded Videos
    19. Automotive Work
    20. Electronics
    21. Home Workshop/Do-It-
                Yourself
    22. Recreation Vehicles (RVs)
    23. Listen to Records/Tapes/CDs
    24. Avid Book Reading
    25. Bible/Devotional Reading     		26. Health/Natural Foods
    27. Photography
    28. Cultural/Arts Events
    29. Fashion Clothing
    30. Art/Antique Collecting
    31. Foreign Travel
    32. Cruise Ship Vacations
    33. Travel in USA
    34. Gourmet Cooking/Fine Foods
    35. Wines
    36. Stamp/Coin Collecting
    37. Collectibles
    38. Our Nation’s Heritage
    39. Real Estate Investments
    40. Stocks/Bond Investments
    41. Contests/Sweepstakes
    42. Casino Gambling
    43. Science Fiction
    44. Wildlife/Environmental Issues
    45. Dieting/Weight Control
    46. Science/New Technology
    47. Self-Improvement
    48. Walking for Health
    49. Watching Sports on TV
    50. Home Video Recording
    51. Moneymaking Opportunities
    24.  
  24. Using the numbers in the above list, please indicate your 3 most important activities:
     
           




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