A Day in your Life | QuestionPro

What is your Age?

18-22

23-30

31-40

41-50

51-60

61+

What is your ethnicity?

Do you have any physical limitations (select all that apply)?

I do not have any limitations

Vision

Hearing

Mobility with use of aids (for example: wheel chair, crutches, or canes)

Mobility but so not require the use of aids (for example: limited mobility in legs, arms, or neck)

Other-please describe

Do you depend on another person to assist you in your daily life?

Yes

No

What is your marrital status?

Single

Married

Divorsed

Widowed

How many kids do you have?

What is your employment status?

Umemployed

Employed but work from home

Employed and work outside of the house

Homemaker

Describe your Morning routine. (for eaxample: read the paper, hours spent talking or texting, hours of TV watched, Drive time in car and commonly visited locations) Please be as detailed as possible.

Describe your afternoon routine. (for eaxample: read the paper, hours spent talking or texting, hours of TV watched, Drive time in car and commonly visited locations) Please be as detailed as possible.

Describe your Evening routine. (for eaxample: read the paper, hours spent talking or texting, hours of TV watched, Drive time in car and commonly visited locations) Please be as detailed as possible.