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 partner’s/spouse’s 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