Survey about Headaches

What is your birth date?

Please indicate your gender.

Male

Female

Have you ever had any of the following health problems? (check ONE box for each problem listed in the Column "3A". Answer Questions "3B" to "3D" for each YES in Column "3A"

	"3A" Ever had this health problem?	"3B" If Yes, did a Dr. confirm this diagnosis?	"3C" Are you currently taking medications for this condition?	"3D" How old were you at first occurence?
Depression

Anxiety

Sleep Apnea

Dysphasia (difficulty swallowing)

Urinary Incontinence or Overactive Bladder (leckage of urine when you laugh or cough or a sense of urgency to urinate)

Cervical Dystonia

Compared to NOW, how do you think you will rate your health in general next year? (Check one)

Much better next year

Somewhat better next year

About the same as now

Somewhat worse next year

Much worse next year

Please tell us what types of leisure activities you enjoy? (Check as many as apply)

Family activities

Solo activities

Activities with friends (non-relations)

Activities with non-personal groups (like concerts)

Other

Please rank the following leisure activities in order of preference.

Spend time with my family
Go to a movie
Do some strenuous outdoor activity
Go to the gym
Read a book
Watch TV

Please tell us where the time in your NORMAL weekday goes. Total must sum to 100.

Paid work

Housework

Family time

Personal leisure activity (like watching TV)

Running errands

Commuting between activities

0

During the past 4 weeks, how much of the time have your physical health or emotional problems interfered with your social activities?

What is your street address?

Contact Information

* First Name :

* Last Name :

* Address 1 :

Address 2 :

* City :

* State :

* Zip :

Best Phone Number to Reach You :

Email Address :

Test VR