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 |