Longitudinal Study Participant Questionnaire
Please complete this questionnaire to help us track your progress and experiences throughout the study.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Female
Male
Non-binary
Prefer not to say
Other
How would you rate your overall well-being over the past month?
*
1
2
3
4
5
Please indicate how much you agree with the following statements:
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I feel supported by my community.
1
2
3
4
5
I am able to manage my daily stress.
6
7
8
9
10
I am satisfied with my current health.
11
12
13
14
15
I regularly engage in physical activity.
16
17
18
19
20
Which of the following best describes your current employment status?
Employed full-time
Employed part-time
Unemployed
Student
Retired
Other
Select the health conditions you have been diagnosed with (select all that apply):
Hypertension
Diabetes
Asthma
None
Other
How many hours per week do you spend on physical activity?
Please share any additional comments or experiences relevant to the study.
Submit Questionnaire
Should be Empty: