Comprehensive Health and Nutrition Assessment

Health & Lifestyle Survey

Please take 5–10 minutes. Fields marked with * are required.

This form collects sensitive information (e.g., health and demographic data). We use it only for assessment and research related to this project. Your responses are kept confidential and will not be sold. You may skip optional questions and can withdraw at any time.

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Consent

I consent to participate and for my data to be used as described above *

If you do not consent, do not submit this form.

Participant Information

1. What is your full name? *

2. What is your date of birth? *

3. What is your email address? *

4. What is your phone number?

5. What is your address?

6. What is your ethnicity? Prefer not to say American Indian or Alaska Native Asian Black or African American Hispanic or Latino Middle Eastern or North African Native Hawaiian or Other Pacific Islander White Multiple Other (specify below)

7. What is your genetical gender? Prefer not to say Female Male Intersex / differences of sex development Other (specify below)

If you intended “sex assigned at birth,” you may indicate that here.

Background

8. Describe the places you have lived over your lifespan and for how long:

0 / 3000

9. Describe your present family: the number of members and ages:

0 / 2000

Lifestyle

10. How often and for how long do you exercise in a typical week? Describe the type of exercise and where you do it:

0 / 2000

11. What is your career and what work and general routine does your daily workday consist of?

0 / 2000

12. Describe in elaborate detail your dietary habits. (See prompt.)

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Include typical breakfast/lunch/dinner, approximate quantities, condiments (butter/oil/dressings/spreads), yesterday’s intake if remembered, number and timing of meals.

Leisure, Travel & Family History

13. What do you do in your spare time? (e.g., hobbies, religious activities, time with family/friends)

0 / 2000

14. Do you travel frequently? Please explain.

0 / 2000

15. Please list all those in your immediate and extended family that have a disease and what disease he/she has (e.g., cancer, cardiovascular disease, asthma, diabetes, degenerative brain disease, mental illness, etc.).

0 / 4000

Health Measurements & History

16. What is your body weight in pounds?

17. What is your waist circumference in inches?

18. What is your hip circumference in inches? 19. What medical conditions have you been diagnosed with and when?

0 / 4000

20. What are your health concerns?

0 / 3000

21. What are your health and weight loss goals?

0 / 3000

22. Have you had any surgical operations or major medical procedures? Please explain:

0 / 4000

* Required field