Longitudinal Health Study Questionnaire
Please complete this questionnaire to help us monitor your health and well-being over time. Your responses will remain confidential and are vital for our research.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Gender
*
Male
Female
Non-binary
Prefer not to say
Other
Current Health Conditions (select all that apply)
*
Diabetes
Hypertension
Asthma
Heart Disease
None
Other
Are you currently taking any medication?
*
Yes
No
Please list your current medications (if any)
Lifestyle Habits
*
Rows
Never
Occasionally
Regularly
Tobacco Use
1
2
3
Alcohol Consumption
4
5
6
Physical Exercise
7
8
9
How would you rate your overall health?
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Over the past 2 weeks, how often have you felt down, depressed, or hopeless?
*
Not at all
Several days
More than half the days
Nearly every day
Submit Questionnaire
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