Census Division:

• New England Division
• Middle Atlantic Division
• East North Central Division
• West North Central Division
• South Atlantic Division
• East South Central Division
• West South Central Division
• Mountain Division
• Pacific Division

Census Region:

• Northeast Region
• Midwest Region
• South Region
• West Region

County Size:

• A
• B
• C
• D

What is your gender?

• Male
• Female

Age:

• 18-20
• 21-24
• 25-29
• 30-34
• 35-39
• 40-44
• 45-49
• 50-54
• 55-59
• 60-64
• 65-69
• 70-74
• 75-79
• 80-84
• 85+

Race:

• White
• American Indian or Alaska Native
• Black or African American
• Asian or Pacific Islander
• Other

Are you Spanish, Hispanic, or Latino?

Thinking about the language you use/speak at home, would you say you speak…

• Only Spanish at home
• Mostly Spanish, but some English
• Spanish and English about equally at home
• Mostly English, but some Spanish
• Only English at home

Which of the following best describes you?

• Married
• Single, never married
• Divorced
• Widowed
• Legally separated
• Domestic partnership

Which of the following best represents how you think of yourself?

• Straight or heterosexual
• Lesbian, gay, or homosexual
• Bisexual
• Something else
• Decline

What is the highest level of education you have completed?

• Attended high school or less
• Graduated high school
• Attended college/junior college/technical/vocational school (no degree)
• Associate’s degree (occupation/vocation/academic)
• Bachelor’s degree (BA, AB, BS)
• Post graduate study (no degree)
• Master’s degree (MA, MS, MENG, MED, MSW, MBA)
• Professional degree (MD, DDS, DVM, J.D.)
• Doctorate degree (Ph.D., Ed.D.)

Current Employment Status:

• Full-time (30 hours per week or more)
• Part-time (less than 30 hours per week)
• Full-time student
• Not employed
• Retired

Are you self-employed?

What is the total annual personal income from your job?

• Less than $20,000
• $20,000-$29,999
• $30,000-$39,999
• $40,000-$49,999
• $50,000-$59,999
• $60,000-$74,999
• $75,000-$99,999
• $100,000-$124,999
• $125,000-$149,999
• $150,000-$249,999
• $250,000 or more

What is the total annual income of your household before taxes?

• Less than $20,000
• $20,000-$29,999
• $30,000-$39,999
• $40,000-$49,999
• $50,000-$59,999
• $60,000-$74,999
• $75,000-$99,999
• $100,000-$124,999
• $125,000-$149,999
• $150,000-$249,999
• $250,000 or more

How many adults (18 or older) are living in your household?

Males age 18 or older, Females age 18 or older

• 0
• 1
• 2
• 3
• 4
• 5 or more

Are you a parent of a child (by birth or adoption) who is under age 18?

How many children in each of the age groups below are living in your household?

Number of children: 0, 1, 2, 3, 4, 5 or more, Decline

• Less than 12 months old
• 12 months to less than 24 months old
• 2 to 5 years old
• 6 to 11 years old
• 12 to 17 years old

Does your household own or rent your primary residence (that is the house, co-op, condo or apartment where you live most often)?

• Own
• Rent
• Other

Overall, how would you describe your current health?

• Excellent
• Very good
• Good
• Fair
• Poor

How is your health compared with a year ago?

• Much better
• Somewhat better
• About the same
• Somewhat worse
• Much worse

Overall, how would you describe your current stress level?

• Very stressed
• Somewhat stressed
• Not very stressed
• Not at all stressed

How is your stress level compared with a year ago?

• Much higher
• Somewhat higher
• About the same
• Somewhat lower
• Much lower

What is your outlook regarding your future health?

• Very optimistic
• Somewhat optimistic
• Neutral
• Somewhat pessimistic
• Very pessimistic

Overall, how much control do you believe you personally have over your health?

• Complete control over my health (10)
• Mostly in control over my health (8-9)
• Some control over my health (5-7)
• Little or no control over my health (0-4)

Please indicate how much each item motivates you to maintain or improve your health.

Scale question: 1 (Not at all motivating) to 7 (Extremely motivating)

• To live a long life
• To look good

Thinking about the last 7 days, how many of those days did you exercise or engage in strenuous physical labor for 30 minutes or more at one time?

Please indicate how much of a barrier each of the following is to you in pursuing a regular exercise program.

Scale question: 1 (Not a barrier) to 5 (A very significant barrier)

• I have a medical condition which prevents me from exercising
• It’s easier for me to find excuses not to exercise than to go out and do something

What is your height in feet and inches?

What is your weight in pounds?

BMI Standard

• 1 (Underweight = <18.5)
• 2 (Normal weight =  18.5-24.9)
• 3 (Overweight = 25-29.9)
• 4 (Obesity = BMI of 30 or greater)

BMI Details

• Severely underweight (<16)
• Underweight (16 - 18.49)
• Normal (18.5 - 24.99)
• Overweight (25 - 29.99)
• Obese Class I (30 -34.99)
• Obese Class II (35 -39.99)
• Obese Class III (>=40)

How would you evaluate your diet at home in terms of health and wellness? Please type in a number from 0-100, where 0 represents completely unhealthy and 100 represents completely healthy.

• Terciles 1 (Healthy Diet)
• Terciles 2 (Average Diet)
• Terciles 3 (Unhealthy Diet)

Overall level of concern regarding the healthiness of your diet.

• Extremely concerned (10)
• Mostly concerned (7-9)
• Somewhat concerned (4-6)
• Slightly concerned (1-3)
• Not at all concerned (0)

Are you currently managing your diet or daily nutrition for any of the following reasons?

• I am lactose intolerant
• I have food allergies
• To achieve good health
• To control blood pressure
• To gain weight
• To lose weight
• To lower/maintain blood glucose levels
• To lower/maintain cholesterol levels
• To maintain weight
• Some other reason
• I am not currently managing my diet or nutrition

What types of food do you eat as part of your diet or nutrition plan?

• Fat free
• Gluten free
• Grain free
• High fiber/whole grain
• High protein
• Lactose free
• Low calorie
• Low carbohydrate
• Low cholesterol
• Low fat
• Low sodium
• Natural or organic
• Probiotic
• Raw food
• Sugar free
• Vegan
• Vegetarian
• Other
• None

You mentioned that you are dieting to lose weight, what is your overall weight loss goal?

• 1 to 10 pounds
• 11 to 20 pounds
• 21 to 30 pounds
• 31 to 40 pounds
• 41 to 50 pounds
• 51 to 100 pounds
• 101 pounds or more

Which diet or nutrition program do you participate in?

• Atkins/Eco Atkins
• DASH Diet
• Diet book
• Doctor-created
• Jenny Craig
• Meal replacement
• NutriSystem
• Non-prescription weight loss drugs
• Prescription weight loss drugs
• Self-created
• South Beach Diet
• Weight Watchers
• Other weight loss program

How much do you agree or disagree with each of the following statements?

Agree a lot, Agree a little, Neither agree nor disagree, Disagree a little, Disagree a lot

• Diet plans usually work for me
• Exercise is important to my diet and nutrition plan
• I can’t seem to adhere to a diet plan and often “cheat” when I’m on one
• I diet to look good more than I diet to feel good
• Weight loss surgery is an option for me

Which of these sports or leisure activities do you regularly play or participate in?

• SPORTS & EXERCISE
• Aerobics
• Baseball/Softball
• Basketball
• Bicycling
• Bowling
• Dancing
• Fantasy Sports League
• Fitness Walking
• Football
• Golf
• Ice Skating
• Running/Jogging
• Soccer
• Swimming
• Tennis
• Use a Health Club/Gym
• Weight Training
• Yoga/Pilates
• OUTDOORS
• Bird Watching
• Fishing
• Gardening
• Hiking
• Hunting
• Sailing/Water Skiing
• Snow Skiing/Snowboarding
• Travel
• ARTS & ENTERTAINMENT
• Attend a Concert/Live Theater
• Attend Professional/College Sports Events
• Entertaining Friends/Family
• Fine dining/eating out
• Go to Bars/Nightclubs
• Go to the movies
• Photography
• Play a Musical Instrument
• Poker
• Shopping for Fun
• Spa Services
• Video Gaming
• Visit Museums
• SELF-IMPROVEMENT
• Adult Education Courses
• Cooking for Fun
• Crossword puzzles/word games
• Reading Books
• Volunteer your Time

How much do you agree or disagree with each of the following statements?

Agree a lot, Agree a little, Neither agree nor disagree, Disagree a little, Disagree a lot

• Everyone should just age naturally
• I spend a lot of money on beauty and skincare products
• I would consider cosmetic surgery for myself, now or in the future

Do you currently smoke or use any tobacco products on a regular basis (at least 5 cigarettes/pipes/pinches/plugs per week)?

• Yes, I smoke cigarettes
• Yes, I chew tobacco or use “snuff”
• Yes, I use electronic cigarettes or vaporizers
• Yes, I smoke cigars
• Yes, I smoke a pipe
• No, I don’t smoke/use any on a regular basis

How many packs of cigarettes did you smoke in the last 7 days?

• Less than 1 pack
• 1-4 packs
• 5-8 packs
• 9 or more packs

Have you ever tried to quit smoking?

• Yes, currently
• Yes, in the past
• No, never