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How old are you?
Under 18
18 - 25
26 - 33
34 - 40
41 - 49
50 and Up

Your Gender is?
Male
Female
Other

How physically fit would you say you are?
Are you kidding? I work out every day!
I'm not a health nut, but I'm in pretty good shape.
I could use a little work.
Ehh... I've kind of let myself go.

Do you have any vices or addictions (check all that apply)?
I smoke regularly.
I'm a heavy drinker.
I use a street drug at more than just a recreational level.
Nope, not really.

Do you have any special needs, or serious medical conditions (check all that apply)?
Yes, I have a physical disability (blindness, deafness, paralysis, prosthetic limb, etc).
Yes, I have a disease or condition requiring regular medical maintenance (diabetes, fibromyalgia, epilepsy, etc).
No, not really.

If you checked "yes" to diseases or conditions above, do you regularly take medication that you need to function?
Yes, I really need my medication.
Yes, but I could probably get by without my meds.
No, I don't have a condition needing medication.

Where do you live?
Big city/Metropolitan area
Suburbs
Fairly large city
Small to medium sized town
Rural/Country

What style of home do you reside in?
House
Apartment/Dorm
Trailer
Homeless/I move around

How about your family (check all that apply)?
I have young children at home.
I live alone.
I live with roommate(s)/significant other.
I live with parents/siblings.