Were you born premature or with any health conditions

Question

Question 1: What is your age? Were you born premature or with any health conditions?

Question 2: What was your birth weight? What is your current height and weight?

Question 3: What is your ethnic background?

Question 4: Which city and which neighborhood did you grow up in?

Question 5: How many schools have you attended and why?

Question 6: Who lived in the home with you where you were raised?

Question 7: What is your parent's education level?

Question 8: How would you classify your relationship with your parents?

• Great/Healthy
• Neutral
• Not Good/Unhealthy/Dysfunctional

Question 9: What was the income range of the person/people who raised you?

• $0-$20,000/year
• $20,000-40,000/year
• $40,000-60,000/year
• $60,000-80,000/year
• More than $80,000/year

Question 10: Have you ever been abused (sexually, physically, or emotionally)?

Question 11: What challenges have you had to overcome in your life? How do you think these challenges have impacted you?

Question 12: What physical disabilities do you have?

Question 13: What mental health conditions have you been diagnosed with or feel you may have?

Question 14: What grades did you earn in grades K-12?

Question 15: Which extracurricular activities did you participate in?

Question 16: What is your highest level of education?

Question 17: List each job you have had and how long you worked there.

Question 18: What religion were you raised in? What is your religion now?

Question 19: Which of the following illnesses or diseases run in your family:

• Diabetes
• Heart Disease
• High Blood Pressure
• High Cholesterol
• Mental Illness (depression, anxiety, eating disorders, bipolar, ADHD, schizophrenia, addiction and substance abuse, PTSD, insomnia, other)
• Cancer

Question 20: How often do you socialize with friends each month?

Question 21: Describe your diet and exercise throughout your life:

Birth to age 18

• Healthy (range of fruits, vegetables, protein, dairy, and carbohydrates)
• Neutral (some fruits, vegetables, protein, dairy, and carbohydrates, but some junk food and fast food)
• Unhealthy (too many calories or not enough calories, low levels of fruit, vegetables, protein, dairy, carbohydrates, high levels of junk food and fast food)

Question 22: How would you describe your personality? (i.e. optimistic/pessimistic, angry/happy, easy-going/high strung, etc.)

Question 23: Were you exposed to asbestos, lead paint, second-hand smoke, or poor water quality growing up?

Question 24: Did you go to annual medical, dental, and vision appointments growing up? When were your last appointments for these?

Question 25: Have you experienced or witnessed domestic violence?

Question 26: How many and which languages were spoken in your home growing up?

Question 27: Did your parents read to you as a child? What was your access to books and toys?

Question 28: Did your parents drink alcohol or use drugs while you were growing up?

Question 29: Did your mother drink or use drugs while pregnant with you?

Question 30: Were you ever neglected or abandoned?