1. What is your date of birth?	Year________	Month________	Day_______
2. What is your sex?	Female______	Male______
3. What is your weight?	Pounds______	Kilograms______
4. What is your height?	Feet________	Centimeters_____
5. What is your marital status?
_______Married
_______Living common-law
_______Living with partner
_______Widowed
_______Separated
_______Divorced
_______Single, never married
6. What is the highest level of education you have completed:
_______No schooling
_______Elementary
_______Junior high
_______High school
_______Non-university/college certificate eg, school of nursing
_______University degree:
_______Partial
_______Undergraduate
_______Graduate
7. What is your employment status?
_______Employed full-time
_______Employed part-time
_______Unemployed
_______Retired
_______Student
_______Disability
8. What do you consider your current main activity?
_______Caring for family
_______Working for wages or salary
_______Caring for family and working for wages or salary
_______Going to school
_______Recovering from illness
_______Looking for jobs
_______Retired
_______Others
9. General health status
_______Excellent
_______Very good
_______Good
_______Fair
_______Poor
10. Now I’d like to ask about any chronic health conditions that you may have. A chronic condition is a long-term condition that has lasted for 6 months or more. Please read the list and mark all that apply.