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Help us gather insight on your health
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How old are you?
Under 18
18-24
25-34
35-44
45-54
55-64
65 or over
What is your gender?
Male
Female
What is your ethnic background?
White
Black or African American
Asian
Hispanic or Latino
Native American
Other
How would you rate your physical health?
Excellent
Good
Fair
Poor
Very Poor
How would you rate your overall mental/emotional health?
Excellent
Good
Fair
Poor
Very Poor
How would you rate your stress levels?
Very low
Low
Moderate
High
Very high
Do you have any chronic health conditions?
Yes
No
Please specify your chronic health conditions
Do you have any hereditary conditions/diseases?
High Blood Pressure
Diabetes
Hemophilia
Thalassemia
Huntington
Other
Please specify your hereditary conditions/diseases
Do you smoke or use tobacco products?
Yes
No
How often do you consume alcohol?
Never
Rarely
Socially
Occasionally
Regularly
How would you rate your level of physical activity?
Sedentary
Light
Moderate
High
Very high
How many hours of sleep do you typically get per night?
Less than 5 hours
5-6 hours
7-8 hours
9-10 hours
More than 10 hours
Have you experienced any significant weight changes in the past year?
Yes
No
Do you have any allergies?
Yes
No
Healthcare Services
How often do you visit your primary care physician?
Once a year or less
2-3 times a year
4-6 times a year
More than 6 times a year
Have you ever been admitted to the hospital?
Yes
No
Please specify your reason for hospitalization
Do you have health insurance?
Yes
No
If you do not have health insurance, why not?
Can’t afford it
Don’t think I need it
Don’t know how to get it
Other
Please share any additional comments or concerns regarding your health
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