Select Your Language / Elejir Su Idioma

English

Español

By completing this questionnaire, I authorize Brand Activation Maximizer, LLC ("BAM”) to receive the information I enter into the questionnaire, which may include information that is considered “protected health information” (“PHI”) under the Health Insurance Portability and Accountability Act (“HIPAA”). I further understand, acknowledge, and agree to the following:

  • BAM will abide by any and all applicable laws and regulations relating to the handling and storage of the information I enter into this questionnaire, including HIPAA and the Health and Information Technology for Economic & Clinical Health Act (“HITECH”);
  • BAM will not allow access to this information to any third party without my express written authorization;
  • I hereby agree to receive communications from BAM, including without limitation through electronic mail and/or text messages, that include suggested information for me to explore, in my sole discretion, based upon my answers to this questionnaire; and
  • I have the right to revoke this authorization, in writing, at any time; provided, however, that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization.

Select your gender:

M

F

Other

Select your age group:

<18

19-30

31-49

50-64

65+

Yes

No

Yes – Asthma

Yes – COPD

No

Do you use CPAP equipment?

Yes

No

Vaccination Services

Nutrition

Pharmacy

Clinic

Chronic Obstructive Pulmonary Disease (COPD)

Asthma

Lung Cancer Screening

Lung Cancer in Women

Lung Cancer in Never Smokers

How likely are you to recommend Kroger Health?

1

2

3

4

5

6

7

8

9

10

Thank you for your interest in the Kroger Health Survey! This survey is only available for users over 18 years old.