Sex?
Select one... Male Female

What is your Age?
Select a range... 18 - 24 25 - 34 35 - 44 45 - 54 55 - 64 65 or older

Race
Select one... White Non-Hispanic Black Non-Hispanic American Indian Asian Non-Hispanic Native Hawaiian Other Race Only Non-Hispanic Multiracial Non-Hispanic Hispanic Not Sure

Marital Status
Select one... Married Divorced Widowd Separated Never Married Member of an unmarried couple

What do you think is your General Health?
Select one... Excellent Very Good Good Fair Poor

Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good (1-30 number of days, 88 none)?

Ever told you that you have a depressive disorder, including depression, major depression, dysthymia, or minor depression?
Select one... Yes No

Is your body mass index greater than 25.00?
Select one... No Yes

What is the highest grade or year of school you completed?
Select one... Never attended or kindergarted Elementary Some High School High School Graduate High School Graduate College Graduate

Annual household income from all sources:
Select one... Less that 10k 10K to less 15k 5k to less than 20k 20k to less than 25k 25k to less than 35k 35k to less than 50k 50k to less than 75k 75k or more

Was there a time in the past 12 months when you needed to see a doctor but could not because of cost?
Select one... Yes No

Smoker?
Select one... No Yes

Heavy drinkers (adult men having more than 14 drinks per week and adult women having more than 7 drinks per week)
Select one... No Yes

Consume Fruit 1 or more times per day
Select one... Yes No

Consume Vegetables 1 or more times per day
Select one... Yes No

How active are you?
Select one... Highly Active Active Insufficiently Active Inactive

Have you done any physical activity or exercise during the past 30 days other than their regular job?
Select one... Had Physical Activity No Physical Activity