Healthy Aging Survey
Share your experiences and habits to help us understand factors that contribute to healthy aging.
Full Name
*
First Name
Last Name
Age
*
Gender
*
Female
Male
Non-binary
Prefer not to say
How would you rate your overall health?
*
Excellent
Very Good
Good
Fair
Poor
In the past week, how many days did you engage in physical activity (such as walking, exercise, or sports)?
*
0 days
1-2 days
3-4 days
5-7 days
How often do you eat fruits and vegetables?
*
Rarely
Some days
Most days
Every day
How would you describe your sleep quality?
*
Very poor
Poor
Average
Good
Excellent
How often do you feel socially connected to others?
*
Never
Rarely
Sometimes
Often
Always
Please indicate how much you agree with the following statements.
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I feel positive about aging.
1
2
3
4
5
I am able to manage my daily activities independently.
6
7
8
9
10
I feel satisfied with my life.
11
12
13
14
15
I am interested in learning new things.
16
17
18
19
20
How would you rate your overall satisfaction with your life as you age?
*
1
2
3
4
5
Is there anything else you would like to share about healthy aging?
Submit Survey
Should be Empty: