Questionare
1. How old are you?
−
+
2. Gender?
Male
Female
3. What is Your Education Level?
None
Never attended school or only kindergarten
Grades 1 - 8 (Elementary)
Grades 9 - 11 (High school)
Grade 12 or GED (High school graduate)
College 1 year to 3 years (Some college or technical school)
College 4 years or more (College graduate)
4. What is is your income level?
[Note: In Dollars]
−
+
5. Do you have high Blood Pressure?
No
6. Do you have high Cholesterol?
No
7. Do you have high blood Glucose?
No
8. Do you have take medication for high Blood Pressure?
No
9. On a Scale of 5 to 1. How would you rate
your Health in General?
[Note: 5 being the worst and 1 being the best!]
5
10. For how many days during the past 30
days was your mental health not good?
−
+
11. For how many days during the past 30
days was your physical health not good?
−
+
12. Do you have a difficulty walking up stairs?
No
13. Are you Physically Active?
No
14. Do you do Daily Exercise?
No
15. What is your waist circumference?
cm
16. Have you done any physical activity in the past month?
No
17. What is Your Weight?
kg
lbs
18. What is Your Height?
meters
m
19. Have you smoked at least a 100 cigarettes in you life?
[Note: 5 packs = 100 cigarettes]
No
20. How many drinks do you have in a week?
[Note: Thats in 7 days]
−
+
21. Have you ever had a Stroke?
No
22. Have you ever had any Coronary heart disease or Heart Attack?
No
23. Have you ever had any Gestational Diabetes?
[Note: Only for females]
No
24. Do you Consume Fruits Everyday?
No
25. Do you Consume Vegetables Everyday?
No
26. Do your Grandparents, Uncle, Aunt or First Cousins have any diabetes?
No
27. Do your Parents, Siblings or Child have Diabetes?
No
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