Don’t be shy—your privacy is our top priority and we take it very seriously. Getting to know a little about you is an important part of developing your health record and helping you to achieve your goals.

Personal History

What is the highest education level you have completed?

Up to 12th grade in high school
High school diploma or GED certificate
Some college or technical trade school
Technical/trade school degree
Junior College degree
College degree (B.S., B.A., A.B.)
Some Post Graduate education
Post Graduate Degree (M.S., M.A., M.D., Ph.D.)

Of the sentences below, which best describes your employment status?

I work full-time (40 hours per week)
I am a full-time student
I work part-time
I am unemployed
I am a homemaker
I am retired.

What is your ethnic background?

African American or Black
Alaskan Native
Asian (non-Pacific Islander)
Caucasian or White
Hispanic
Native American
Pacific Islander
Other

Projected yearly household income

Less than $35,000
35,000-49,999
50,000-74,999
75,000-95,999
100,000-250,000
250,000+

Check all of the regions in which you have lived

Canada and/or Western Europe
U.S.
Pacific Islands
Asia
Africa
Latin America
Eastern or Central Europe

How would you describe your current marital status, If you consider yourself in a permanent cohabited relationship check married.

Never married
Happily married
Unhappily married
Separated
Divorced
Widow/widower