AXANTEUS PANEL

Axanteus Panel is a global community of diverse individuals who are interested and motivated in providing their feedback in order to improve products and services which they have used or considered using.

As a member, you will be able to participate in many interesting surveys, learn about new products and services and earn remuneration along the way.

Your personal information will be kept safe and strictly confidential within our company, and will not be used for any other purpose other than market research or passed to another organization without your approval.

If you are interested in joining this community, please register with us

here.

Axanteus Panel

    Personal Information



    Date of Birth*:


    MaleFemale


    MarriedUnmarriedSeparated / Divorced / Widowed






    Contact Information



    Employment Information



    Other Position:





    Other Services (Please specify):

    Assets & Ownership


    Other Residence:


    Real EstateStocksBondsUnit Trusts & Mutual FundsForexCryptocurrenciesNotes & CoinsCommoditiesArt & AntiquesDerivatives

    Household Monthly Income In USD*:


    Other Make:

    Model of Car:

    Types of Products Owned :
    Desktop ComputerLaptop ComputerTablet ComputerMobile PhoneTelevisionBroadband Internet Access at HomeCamera (as a separate device)Video Camera (as a separate device)Motorized Personal Mobility Device (e-scooter, hoverboards, e-unicycles etc)Game Console (Xbox, Wii, Playstation etc)

    Qualifications

    Educational Qualification*:

    Languages Proficient In*:

    Medical History

    Do you have any medical history that you are comfortable speaking about*: (tick NIL if no medical history)
    High/low blood pressure (Hypertension/Hypotension)Diabetes I/IIEye conditions (Astigmatism, Cataract, Colour Blind, Glaucoma, Myopia, etc.)Skin disease (Acne, Atopic Dermatitis, Eczema, Psoriasis, etc.)Chronic pain (Arthritis, Migraine, Carpal Tunnel, Osteoarthritis, Slipped Discs, Scoliosis, etc.)Physical disabilities (Cerebral Palsy, Epilepsy, Muscular Dystrophy, Spina Bifida, Spinal Cord Injury, etc.)Lung disease (Asthma, Bronchitis, Tuberculosis, etc.)Kidney disease (Acute Renal Failure, Chronic Kidney Disease, Kidney Failure, Kidney Stones, etc.)Liver disease (Hepatitis A/B/C, Fatty Liver Disease, Liver Cirrhosis, Liver Fibrosis, etc.)Blood disorders (Anemia, Hemophilia, etc.)Cardiovascular disease (Arrhythmia, Cardiomyopathy, Heart Attack, Heart Failure, Stroke, etc.)Cancer (Breast, Cervical, Colo-rectum, Kidney, Leukemia, Lung, Lymphoma, etc.)Cosmetic dentistry (Teeth Whitening, Dental Bonding, Dental Crowns, Dental Veneers)Cosmetic procedures (Botox, Breast Augmentation, Eyelid Surgery, Facelift, LASIK, Liposuction, Rhinoplasty)Sexually Transmitted Disease (Chlamydia, Gonorrhea, Herpes, Hepatitis, HIV, HPV, Syphilis, etc.)Mental health conditions (Anxiety, Bipolar Disorder, Depression, Schizophrenia, Substance Abuse, etc.)NILOther medical history not included above

    Other medical history, please specify