*First Name:	*Last Name:
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*Birth date:
Month 1 2 3 4 5 6 7 8 9 10 11 12  /  Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31  /  Year 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
*Please tell us your gender:
Male Female

*Are you requesting information for yourself or for a friend or family member?
I am requesting for myself
I am requesting for someone else

*Have you been diagnosed with high blood pressure?
Yes
No

*Are you currently taking high blood pressure medication?
Yes
No

*Where did you hear about the BP Success Zone Program?
Advertising At Your Pharmacy BP Success Zone letter Doctor's office (received kit) Friend/Family Member Health insurance company Internet Advertisement Internet Search Engine Magazine/Newspaper Advertisement Magazine/Newspaper Article Mall screenings Other/Don't Remember Pharmacy screenings TV Advertisement TV News Story Toll free number from website Website (other than this one)

*Which of the following best describes how you feel about doctors?

	It is easy for me to depend on and trust healthcare providers. I feel supported.
	I want to be in open, trusting relationships with healthcare providers, but I generally find that they are not as available as I would like. I sometimes worry about not being supported.
	I am somewhat uncomfortable depending on and trusting healthcare providers. I worry that things may turn out badly if I rely on them completely.
	I am uncomfortable depending on healthcare providers. It is very important for me to feel independent and self-reliant.

*On a scale of 1 to 10, compared to other conditions you may have, how serious is having high blood pressure?

(Choose One Number)
	1	2	3	4	5	6	7	8	9	10
Not Serious at All						Very Serious

*As part of the BP Success Zone Program, Novartis Pharmaceuticals would like to send you special offers and additional information about high blood pressure and related health issues. Would you be interested in receiving this additional information?
Yes
No

*We would like to offer you information about other Novartis Pharmaceuticals products, services and programs. Would you be interested in receiving this information?
Yes
No

	To request information by phone call 1-877-744-0747
	Monday to Friday, 8:00 a.m. to 10:00 p.m. EST; Saturday, 8:00 a.m. to 5:00 p.m. EST.