*What is your age? -Please Select- Under 18 18 - 22 23 - 29 30 - 39 40 - 49 50 or Above

*What is your gender? -Please Select- Male Female

What is your sexual orientation? -Please Select- Straight Bisexual Gay Undecided

How many of your grandparents are still alive? -Please Select- Zero One Two Three Four

How many children do you have? -Please Select- Zero One Two Three Four Five or More

What is your marital status? -Please Select- Never Married Married Divorced Re-Married (2nd, 3rd, etc)

How many brothers and sisters do you have? -Please Select- Zero One Two Three Four Five or More

How many good friends do you have? -Please Select- Zero One or Two Three to Five Six to Ten More than Ten

What is your religion? -Please Select- Agnostic or Undecided Atheist Buddhism Christianity Deism Hinduism Islam Judaism New Age Other Scientology Sikhism Wicca

What body-weight are you? -Please Select- Underweight Healthy Weight Slightly Overweight Very Overweight

How recently has someone very important to you died? -Please Select- Zero to Six Months Six Months to a Year One to Two Years Three to Six Years More than Six Years

Other than death of a loved one, have you had a traumatic experience recently?

Yes

No

Have you ever been in prison?

Yes

No

Do you travel?

Yes

No

Do you have any major illnesses?

Yes

No

Do you have any non-major, chronic illnesses?

Yes

No

Do you have any non-illness disabilities?

Yes

No