WRIISC Health Questionnaire             V20151016
 Section 1: General Demographics

       DATE:           TIME (24hr):           WRIISC ID: 

Please complete all items.

Sex (Fill in one answer):    Male       Female

Race (Fill in all that apply):
American Indian or Alaskan Native                Asian       Black or African American
Native Hawaiian or other Pacific Islander       White       Unknown
Other:

Ethnicity (Fill in one answer):      Non Hispanic or Non Latino       Hispanic or Latino       Unknown


Education (Please fill in the highest year of school you completed. Fill in one answer.):

   1    2    3    4    5   6         7    8   9   10  11  12      13 14  15  16       17 18 19  20 21  22      +23
                      

Education (Please fill in all educational degrees obtained):
High School diploma/GED       Technical/Trade School       Associate Degree       Bachelor Degree
Master's Degree       PhD/Doctorate Degree       MD       JD

Other:

Primary Language:

Secondary Language:

Marital Status (Fill in one answer):
Currently Married      Widowed      Divorced      Separated      Never married     
Living with a Partner

Number of years with current partner or spouse: (drop-down menu) - dem_mar_length

Number of time married: (drop-down menu) - dem_mar_times

How is your partnerís/spouseís health? (Fill in one answer.)

Excellent      Very Good      Good      Fair      Poor     

Employment Status (Fill in all that apply.):
Employed full-time      Employed part-time      Unemployed
Student      Homemaker      Retired
Applying for Disability Benefits      Receiving for Disability Benefits

Other:

Are you right or left hand dominant?
Don't know           Right           Left           Both/Ambidextrous


    

Last update:  10/16/2018