| Questionnaire |
| Personal Information |
| What is your gender? |
| Physical Information |
| Birth Date (mm/dd/yyyy) |
| Where were you born? |
| What country are you a citizen of? |
| What is your race? |
| What is your ancestry or ethnic origin? |
| What is your primary language spoken at home? |
| What is your marital status? |
| What is the highest degree or level of School you have completed? |
| Medical History |
| List you allergies. |
| What is your blood type? |
| Has anyone in your family ever had (check box if yes): |
| Diabetes | High Blood Pressure |
| Heart Disease | Cancer |
| Mental Illness | Epilepsy/Seizure |
| Check the box if you have had or received medical treatment for: |
| Diabetes | High Blood Pressure |
| Heart Trouble | Rheumatic Fever |
| Hernia | Frequent Headaches |
| Cancer/Tumor | Dizziness |
| Chronic Cough | Shortness of Breath |
| Chest Pain | Varicose Veins |
| Arthritis/Gout | Asthma |
| Kidney Trouble | Tuberculosis |
| Epilepsy | Back Problems |
| Rash or Skin Trouble | Slipped Disc |
| 20/20 Vision | Wrist Problems |
| Hearing Problems | Fractured Vertebrae |
| Mental Breakdown | Sexually Transmitted Disease |
| Jaundice or Hepatitis | Drug Problems |
| Pregnancy | Menstrual Problems |
| Breast Lumps | Prostate Problems |
| Penile Discharge | Testicular Lumps |
| Habits |
| Do you smoke? | Yes No |
| How many years? | |
| Did you smoke? | Yes No |
| How many years ago did you quit? | |
| How many years did you smoke? | |
| Packs per day? | |
| Do you use or take any drugs regularly? (prescription and non-prescription) |
Yes No |
| What kinds? |
| Would you say that your health is : |
| Economic Information |
| Professional Information |
| Financial Information |
| Residential Information |
| Interests |
| Outdoor Activities / Fitness |
| Aerobics | Biking |
| Boating / Sailing | Camping |
| Fishing | Hiking |
| Hunting | Ice skating |
| Jogging / running | Martial Arts |
| Mountain climbing | In-line skating |
| Snow skiing / Snow boarding | Snowmobiling |
| Swimming | Walking |
| Water skiing | Weight lifting |
| Wind surfing / surfing |
| Sports |
| Auto racing | Participate | Watch | ||
| Baseball / Softball | Participate | Watch | ||
| Basketball | Participate | Watch | ||
| Bowling | Participate | Watch | ||
| Diving | Participate | Watch | ||
| Cricket | Participate | Watch | ||
| Extreme sports | Participate | Watch | ||
| Figure skating | Participate | Watch | ||
| Football | Participate | Watch | ||
| Golf | Participate | Watch | ||
| Hockey | Participate | Watch | ||
| Lacrosse | Participate | Watch | ||
| Olympic Sports | Participate | Watch | ||
| Rugby | Participate | Watch | ||
| Soccer | Participate | Watch | ||
| Squash / Racquetball | Participate | Watch | ||
| Swimming | Participate | Watch | ||
| Tennis | Participate | Watch | ||
| Track and Field | Participate | Watch | ||
| Wrestling | Participate | Watch |
| Entertainment |
| Bars/pubs | Casino/gambling |
| Concerts | Cultural events (Museum/theater/galleries) |
| Dance clubs | Darts |
| Dinner parties at home | Fashion events |
| Fine dining | Games - Board |
| Games - Card | Games - Parlor |
| Games - Video | Movies |
| Music - Classical | Music - Country |
| Music - Pop | Music - Jazz/R & B |
| Music - Rap | Music - Rock |
| Poetry | Reading |
| Surfing the web | TV - Entertainment |
| TV - Educational/News | Wine tasting |
| Hobbies and Other Interests |
| Antiques/furniture restoration | Astrology |
| Cars | Cats |
| Collecting | Computer/software |
| Crafts | Creative writing |
| Dogs | Family/kids |
| Fish/aquarium | Gardening |
| Gourmet cooking | Home improvement |
| Investing | Motorcycles |
| News/politics/Current events | Painting |
| Philosophy/spirituality | Photography |
| Shopping | Social cause/activism |
| Travelling | Volunteer |
| Yoga |
| Computer Experience |
| Do you own a computer? |
How Many?
Operating Systems:
| Windows 95/9 | Windows 2000 |
| Windows ME | Windows XP |
| Windows NT | Mac OS 8.* |
| Max OS 9.* | Max OS X |
| Linux | Unix |
| FreeBSD | Other |
| What do you use your computer(s) for? |
| Word Processing | Multi-Media |
| Accounting | Business Application |
| Spread Sheets | Presentations |
| Internet Access | |
| Printing | Image Creation/Manip |
| 3-D Modeling/Animati | Communication |
| Games | Design |
| Music | Education |
| Internet Access |
Speed of Connection:
| No Connection | 14.4 kbps Modem |
| 28.8 kbps Modem | 56.6 kbps Modem |
| DSL Modem | Cable Modem |
| Satellite Dish | T1 |
| T3 | ISDN |
| other |
How often do you use the internet?
|
Once a day Few times a day Few times a week Few times a month Never |
| What do you use the internet for? |
| General information | Specific information |
| Enquiries to organiz | Networks |
| Chat-rooms | |
| Banking | Learning |
| Council Services | Bookings |
| Leisure | Travel |
| Work | News |
| Payments | Hobbies |
| Shopping | Games |