1 Your Age

2 Sex Male ... Female

3 Marital Status Click to choose >>>>>> Single (Never Married) Engaged Married De Facto Separated Divorced Widow/er

4	In which industry do you currently work?
	Click to choose your option >>>>>>>>>>>>>> Accounting/Auditing Advertising, Marketing & Public Relations Agrigulture, Forestry & Animal Services Architectural Services & Interior Design Arts, Entertainment & Media Automotive Aviation/Aerospace Banking, Finance & Economics Building & Ground Maintenance Childcare Computer Hardware Computer Software Construction & Trades Consulting Services Defence, Emergency & Essential Services Education, Training & Library Employment & Human Resources Engineering Fashion & Beauty Fitness & Weight Loss Food Services & Restaurant Government Graphic Design & Multimedia Healthcare - Complementary & Alternative Healthcare - Laboratory/Pathology Services Healthcare - Medical & Dental Practitioners Healthcare - Medical Records & Informatics Healthcare - Nurses & Nursing Aids Healthcare - Other Healthcare - Pharmacy Healthcare - Social Services/Mental Health Healthcare - Therapy & Rehabilitation Hospitality, Tourism & Travel Information Technology Insurance Internet & E-Commerce Law Enforcement & Security Legal Manufacturing, Production & QA Mining & Industrial Resources Personal Care Services Pharmaceutical & Biotechnology Publishing & Printing Real Estate Retail/Wholesale Science & Research Shipping Sports & Recreation Telecommunications Transport, Warehousing & Logistics Utilities (Oil, Gas & Electricity) Volunteer, Charity & Welfare -------------------------------------------- Home Maker Retired Pensioner Unemployed Student -------------------------------------------- Other (Please Specify) >>>>>>>>>>>>>>>>>	Other:

5	What is the approximate combined yearly income of all the people living in your household.
	Click to choose option >>>>>>> Less than $30,000 per year Between $30,000 and $50,000 Between $50,000 and $70,000 Between $70,000 and $90,000 Between $90,000 and $120,000 Between $120,000 and $150,000 Between $150,000 and $200,000 Over $200,000 per year

6	How many children do you have?
	Number of Children 15 years or younger:	Number of Children 16 years or older:

7	How often do you visit a health store?
	Once a month Once every 2 to 3 months Once every 4 to 6 months Once or twice a year Never

8	Which health store(s) are you aware of in your area? Please give store name(s)?

9	What products have you bought/use from a health store?

10	Does someone else in your household, other than yourself, buy products from a health store?
	Yes .......... No

11	Does someone else in your household buy products from a health store specifically for you?
	Yes .......... No

12	If you answered yes to question 11 (above), who in your household buys products from a health store for you?
	Spouse Partner Parent Relative Friend Other (Please Specify)

13	What would encourage you to visit a health store more regularly?

14	Do you visit a pharmacy 2 or more times per month?
	Yes .......... No

15

What types of products do you buy at the pharmacy? (Tick all that apply)

Prescription Medicines Over the counter Medicines Cosmetics Skin Care Products Toiletries Hair Care Products Perfumes Weight Loss Products Baby Care/ Children's Products Dental Care Products Eye Care Products Wound Care Products Mobility and Health Equipment Supplements Gifts and Novelty Items Shoes Bed/Sleep Accessories Food Items Household Items (eg. tissues, toilet paper etc.) Constipation/Diarrhoea Products Products to Manage a Health Condition Other (Please Specify)

16	What products would you like to have available at your pharmacy that you cannot find at the moment?

17	What products does your pharmacy stock regularly that you do not think belong in a pharmacy?

18	Apart from products, what types of services does your pharmacy offer?

19	How much would you typically spend at the pharmacy each visit?
	Click to choose option >>>>>>> Less than $20 Between $20 and $50 Between $50 and $100 Between $100 and $150 Between $150 and $200 More than $200

20	Has your doctor every told you that you need to change your diet and lifestyle to improve a health condition?
	Yes .......... No

21	If you answered yes to question 20 above, did your doctor give you clear instructions about how to change your diet and lifestyle?
	Yes .......... No

22	Which on-line health store(s) do you visit? Please give the web site address for these stores.

23	What types of products/services do you buy from the on-line health store(s) that you visit? Please give descriptions of products.

24	How much do you typically spend at the on-line health store(s) each visit?
	Click to choose option >>>>>>> Less than $20 Between $20 and $50 Between $50 and $100 Between $100 and $150 Between $150 and $200 More than $200

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