Page 06 – N – My health Coach

User ID

Champ requis!

Password

Champ requis!

We now need to collect information from you in order to assess a variety of health-related risks.
However, please note that you can indicate for each question we ask that you would prefer not to disclose the answer to that question

<p style="font-size:16px;">We now need to collect information from you in order to assess a variety of health-related risks. <br />
However, please note that you can indicate for each question we ask that you would prefer not to disclose the answer to that question<br />
</p>

Champ requis!

1. What is your gender?

I prefer not to provide this information

Male

Female

Non Binary

Transgender

Champ requis!

2. What is your highest level of education?

I prefer not to provide this information

Less than high school

High school graduate

Some college

2 year degree

4 year degree

Professional degree

Doctorate

Champ requis!

3. What is your date of birth?

<div class="super-label super-bottom-margin">3. What is your date of birth? </div>

Champ requis!

I prefer not to provide this information

Champ requis!

Select a date

Champ requis!

4. On a typical night, how many hours do you sleep?

I prefer not to provide this information

Less than 6 hours

From 6 to 8 hours

From 8 to 10 hours

More than 10 hours

Champ requis!

5. How often do you exercise in a typical week?

I prefer not to provide this information

Every day

5 times a week

2 to 4 times a week

Once a week

Never

Champ requis!

6. What is your occupation?

I prefer not to provide this information

Farmer

Craftsman, trader, and entrepreneur

Executive or higher intellectual profession

Intermediate profession

Employee

Worker

Retired / Unemployed

Student

Other occupation

Champ requis!

7. How often do you drink alcohol in a typical week?

I prefer not to provide this information

Every day

5 times a week

2 to 4 times a week

Once a week

Never

Champ requis!

8. What is your sexual orientation?

I prefer not to provide this information

Heterosexual

Gay

Bisexual

Asexual

Pansexual

Champ requis!

9. What is your height?

<div class="super-label super-bottom-margin">9. What is your height? </div>

Champ requis!

I prefer not to provide this information

Champ requis!

Height (in feet and inches)

Champ requis!

10. What is your weight?

<div class="super-label super-bottom-margin">10. What is your weight? </div>

Champ requis!

I prefer not to provide this information

Champ requis!

Weights (in pounds)

Champ requis!

11. How often do you smoke/consume marijuana in a typical week?

I prefer not to provide this information

Every day

5 times a week

2 to 4 times a week

Once a week

Never

Champ requis!

12. Have you ever driven after having many drinks?

I prefer not to provide this information

Yes

Champ requis!

13. From the following list of surgery types, pick the most recent one you have had (or No surgery if you have not had any)

I prefer not to provide this information

Cosmetic surgery (nose reshaping, eyelid surgery, facelift, ...)

Medical surgery (cardiac, thoracic, gastrointestinal, ...)

No surgery

Champ requis!

14. While in a relationship, have you ever flirted with somebody other than your partner?

I prefer not to provide this information

Yes

Champ requis!

15. Have you ever watched a pornographic video?

I prefer not to provide this information

Yes

Champ requis!

16. Have you ever had a one-night stand?

I prefer not to provide this information

Yes

Champ requis!

17. How many sexual partners have you had until now in your life?

I prefer not to provide this information

None

From 1 to 3

From 4 to 6

From 7 to 9

More than 10

Champ requis!

18. On the following list of chronic diseases, pick the one that is the most troublesome for you (or none if you don’t have any)

I prefer not to provide this information

Cardiovascular diseases (e.g., hypertension, coronary artery disease)

Diabetes mellitus

Chronic respiratory diseases (e.g., asthma, Chronic obstructive pulmonary disease)

Cancer Chronic kidney disease

Arthritis Osteoporosis

Neurological disorders (e.g., Alzheimer's disease, Parkinson's disease)

Depression Chronic liver disease

I don’t have any chronic disease

Champ requis!

19. On the following list of drugs you are currently taking, pick the one that is the most troublesome for you (or none if you don’t have any)

I prefer not to provide this information

Alcohol

Tobacco

Marijuana

Cocaine

Ecstasy

Heroin

Any other drug

I don’t take any drug currently

Champ requis!

20. On the following list of mental disorders you have already experienced yourself in your life, pick the one that is the most troublesome for you (or none if you don’t have any)

I prefer not to provide this information

Depression

Dementia

Parkinson

Alzheimer

Schizophrenia

Bipolar disorder

Post-traumatic disorder

Eating disorder

Other mental disorder

I don’t have any mental disorder

Champ requis!

21. What is your zip code?

<div class="super-label super-bottom-margin">21. What is your zip code? </div>

Champ requis!

I prefer not to provide this information

Champ requis!

zip code

Champ requis!

Please fill in your ID Prolific

Please fill in your ID Prolific

Champ requis!

ID Prolific

Champ requis!

Submit