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Survey
What is your gender?
Male
Female
How tall are you?
Feet
Inches
Change in weight
How much do you weigh now?
How much did you weigh 1 year ago?
No Change in Weight
Did you have intentional weight loss (for example due to dieting or exercise)?
Yes
No
In the last week, how often did you feel that everything you did was an effort?
None of the time
Some or a little of the time (1-2 days)
A moderate amount of the time (3-4 days)
Most of the time (>4 days)
In the last week, how often did you feel that you could not get going?
None of the time
Some or a little of the time (1-2 days)
A moderate amount of the time (3-4 days)
Most of the time (>4 days)
During the past two weeks, have you walked for exercise?
Yes
No
How many times in the past two weeks?
Times in past 2 weeks
How many minutes on average per session do you walk?
0
How many months per year do you walk for exercise?
0
During the past two weeks, have you done moderately strenuous household chores like scrubbing or vacuuming?
Yes
No
How many times in the past two weeks?
Times in past 2 weeks
How many minutes on average per session do you do moderately strenuous household chores?
0
How many months per year do you do moderately strenuous household chores?
0
During the past two weeks, have you done any gardening?
Yes
No
How many times in the past two weeks?
Times in past 2 weeks
How many minutes on average per session do you garden?
0
How many months per year do you garden?
0
During the past two weeks, have you done any general exercise (excluding walking)?
Yes
No
How many times in the past two weeks?
Times in past 2 weeks
How many minutes on average per session do you exercise?
0
How many months per year do you exercise?
0
During the past two weeks, have you mowed a lawn?
Yes
No
How many times in the past two weeks?
Times in past 2 weeks
How many minutes on average per session do you mow the lawn?
0
How many months per year do you mow the lawn?
0
During the past two weeks, have you done any golfing?
Yes
No
How many times in the past two weeks?
Times in past 2 weeks
How many minutes on average per session do you golf?
0
How many months per year do you golf?
0
Have you had any recent pain or acute flare-up in your dominant wrist or hand from conditions like arthritis, tendonitis or carpal tunnel syndrome?
Yes
No
Have you had any surgery on your dominant hand or arm during the last 3 months?
Yes
No
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