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Title *

First Name *

Last Name *

E-mail *

Date of Birth

Home Phone

Format: 123-456-7890. No Extensions

Street Address *

City *

State *

Zip Code *

Mobile

Format: 123-456-7890. No Extensions

Do you or anyone in your household suffer from: (check all that apply)

Cateracts
Glaucoma
Amblyopia
Other Macular Degeneration

Do you or someone you care for suffer from migraine headaches?

Yes, myself
Yes, someone I care for
No

How many migraines do you experience in a month?

0
Less than 5
6 - 10
More than 10

Do you wear contact lenses or glasses?

Contact lenses
Glasses
Both
None

Do you or a loved one suffer from psoriatic arthritis or psoriasis?

Yes, myself
Yes, someone I care for
No

Have you or anyone in your household been diagnosed with cataracts?

Yes
No

Do you or someone you care for currently take medication to treat your migraine headaches?

Yes, myself
Yes, someone I care for
No

Do you or someone you care for have Heartburn, Acid Reflux Disease, or GERD?

Yes, myself
Yes, someone I care for
No

Do you or someone in your household have Diabetes?

Yes, myself
Yes, someone I care for
No

Do you or someone in your household suffer from Asthma?

Yes, myself
Yes, someone I care for
No

Have you or someone in your household been diagnosed with moderate-to-severe Crohn's Disease?

Yes
No

Do you or someone you care for currently have any of the following conditions? (Check all that apply)

Have you been diagnosed with Chronic Obstructive Pulmonary Disease (COPD)?

Yes
No

Do you or a loved one have memory problems (dementia) associated with Alzheimer’s disease?

Yes
No

Have you or a loved one been diagnosed with Multiple Sclerosis?

Yes
No

Do you or a loved one suffer from hemophilia?

Yes
No

Do you or a loved one suffer from hepatitis C, HIV, arthropathy, or renal abnormalities?

Yes
No

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Yes, please customize my weekly newsletter including both content and advertisements which are tailored to me based on my self-reported answers above. I understand that my answers to these questions will help SeniorSymptoms to identify and populate my customized weekly newsletter with the most relevant brands, content, and information and not bombard me with unwanted correspondence. I also understand that I can opt out of these newsletters simply by clicking this link or the corresponding unsubscribe link which is included weekly in my email newsletter.

No thanks, just send me the usual. I prefer that my answers to the above are not used for advertisement and content targeting purposes.