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Personal Data


Phoenix Rising Founder
Arizona in winter & W. North America otherwise

Patient Name:__________________ Todays Date:_______________

Place of residence:___________________Phone no: ( )_____________

30. What is your gender?
 Male
 Female
31. What is your height? _______ feet _______ inches
32. What is your weight? ________pounds
33. What is your marital status?
 Never married
 Married
 Separated/Divorced
 Widowed
 Other
34. What is your ethnic origin or race?
 White
 African-American
 Hispanic or Latino
 Asian
 American Indian or Alaskan Native
 Native Hawaiian or Other Pacific Islander
 Other

35. How much schooling have you had?
 8 grades or less
 Some high school
 High school graduate or GED
 Some college or technical school
 College graduate (bachelors degree)
 Graduate degree
36. Which of the following best describes your current employment status?

 Working full-time, 35 hours or more a week
 Working part-time, less than 35 hours a week
 Unemployed or laid off and looking for work
 Unemployed and not looking for work
 Homemaker
 In school
 Retired
 Disabled, not able to work
 Something else? ________________________
37. How would you describe the health insurance plan(s) you have had in the past 12 months?

 An individual plan the member pays for the plan premium
 The employer pays all or part or the plan premium
 A group plan through an employer, union, etc. which does NOT contribute to premium
 U.S. Governmental Health Plan (e.g., Military, CHAMPUS, VA)
 Medicaid
 Medicare
 I have not had an insurance plan in the past 12 months

38. Which of the categories best describes your total annual combined household income from all sources?
 Less than $15,000
 $15,001 to $30,000
 $30,001 to $50,000
 $50,001 to $75,000
 $75,001 to $100,000
 $100,001 to $150,000
 More than $150,000


What is your height?
2. What is your weight?
3. What is your date of birth?
4. What is your gender?
5. To which of the following race(s) do you belong?
 Black, African-American
 White
 American Indian or Alaska Native
 Asian or Pacific Islander
 Other race (Please specify)
6. Are you of Latino or Hispanic origin?
 Yes  No
7. What is your current marital status?
 Married or living with partner
 Separated
 Widowed
 Divorced
 Never married
8. Do you have any children?
 Yes  No (Skip to Question 9)
8a. How many children do you have?
8b. How many of your children are under 18 years old?
9. How many people live in your home?
10. What grade or degree have you completed in school?
 Less than high school
 Some high school
 High school degree or GED
 Partial college (at least one year) or specialized training
 Standard college degree
 Graduate professional degree including masters and doctorate
11. What is your current work status? (Check all that apply)
 On disability
 Student
 Homemaker
 Retired
 Unemployed
 Working part-time
 Working full-time
11a. If you are on disability, for what condition do you receive disability compensation?
Please Specify
12. What is your current occupation?

12a. If you are currently not working, what was your most recent occupation?
Most Recent


Name_________________________________ Todays date ________________ Address_______________________________________________________________________ City _________________________________ State_____________________Zip ____________ Phone: Home (____) ___________ Work (_____) ___________ Mobile: (____) _____________ E-mail address _________________________________________________________________ Date of birth_________________________________ Age________________________ Male____________ Female___________ Height___________ Weight___________ Body Mass Index (BMI) if known___________ Were you born in the U.S.? ______Yes ______No If yes, place of birth (city and state) ________________________________________________ Do you consider yourself Hispanic/Latino? ______Yes ______No

If you selected Yes, please select the group that represents your Hispanic origin or ancestry: _____ Puerto Rican _____ Dominican Republic _____ Mexican or Mexicano _____ Mexican American _____ Chicano _____ Cuban _____ Cuban American _____ Central or South American _____ Other Latin American _____ Other Hispanic _____ Do not know _____ Refuse to answer What race do you consider yourself to be?
_____ White _____ Black or African American _____ American Indian _____ Alaska Native _____ Native Hawaiian _____ Guamanian _____ Samoan _____ Other Pacific Islander _____ Asian Indian _____ Chinese _____ Filipino _____ Japanese _____ Korean _____ Vietnamese _____ Other Asian _____ Do not know _____ Refuse to answer

Are you pregnant or currently lactating? _____ Yes _____ No _____Not applicable Have you had a baby in the past 3 months? _____ Yes _____ No _____Not applicable Check the one that best describes you: _____Single _____Married _____Widowed
_____Divorced _____ Separated _____ Live in partner _____Refuse to answer

Check the highest grade or level of school you have completed or the highest degree you have received.
We would like to know what you do. Check the one that best describes your current situation.
Including yourself, how many people (related or not) are living or staying at your home?
Are you covered by health insurance or some other kind of health care plan?
What kind of health insurance or health care coverage do you have?
_____High School Graduate _____GED or Equivalent _____Some College _____College Graduate _____Graduate Degree _____Professional Degree _____Refuse to answer
_____Working now _____ Temporarily laid off, sick or maternity leave _____ Looking for work, unemployed _____ Retired _____ Disabled, permanently or temporarily _____ Keeping house _____ Student _____ Other, specify ________________________

_____ Yes _____ No _____ Dont know _____ Refuse
_____ Private health insurance _____ Medicare _____ Medi-Gap _____ Medicaid _____ SCHIP (CHIP, Children's Hlth Ins. Prog.) _____ Military Health Care (Tricare, VA, CHAMP) _____ Indian Health Service _____State-sponsored health plan _____ Other government program _____Single service plan (e.g., prescription drug) _____ No coverage of any type _____Refuse to answer _____Dont know
Do you drink alcoholic beverages? _____ Yes _____ No _____ Dont know _____ Refuse to answer
How many alcoholic beverages do you drink: _____ in a day _____ in a week Do you now smoke cigarettes? _____ Yes
_____ No _____ Dont know _____ Refuse to answer
Have you ever donated blood? If yes, please answer remaining questions
Have you donated blood or blood products in excess of 500 ml within the past 56 days?
How many times have you donated blood or blood products in the past 12 months?
How many times have you donated blood or blood products in the past 10 years?

_____ Yes _____ No _____ Dont know _____ Refuse to answer
_____ Yes _____ No _____ Dont know _____ Refuse to answer
_____ 1 time _____ 2 times _____ 3 times _____ 4 times _____ 5 times ______more than 5 times
_____ 1 to 5 times _____ 6 to 10 times _____ 11 to 20 times _____ more than 20 times

north wales,uk
This is obviously USA orientated, all well and good, but not suitable for UK and the rest of the world. eg health insurance questions not relevant to UK. Is it feasible to have different questionnaires for different places? The ethnicity questions were awkward for outside USA as well.

This is obviously USA orientated, all well and good, but not suitable for UK and the rest of the world. eg health insurance questions not relevant to UK. Is it feasible to have different questionnaires for different places? The ethnicity questions were awkward for outside USA as well.
I am Canadian currently living in the UK.

I know that over here in the UK when you go to the doctor they ask about ethnicity. For instance european is on the list. My family is from the Ukraine/Russia originally plus have English/Welsh relatives. The doctor here likes to know that. (Well actually the government here I believe) I think that there are different diseases that are prevalent due to your heritage. It may be interesting for the survey.

Looks like good work being done on the survey. Will continue to look it over for the next few days to see if there is anything I can offer.

Insurance questions are valid for the UK too as some people have private insurance over here too.



Senior Member
Sth Australia
The earnings on that form... may be very different for different countries. It may be better asking if someone was a low, medium or high income earner.