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Increased Decreased Stayed the same
Very Somewhat Not at all
Always Sometimes Not at all
Personal medical history Family medical history Smoking, alcohol, or drug use Aging-related diseases Family planning and birth control Depression or emotional difficulties When to start treatment and what to start with Side effects
Yes No Not sure
Excellent Good Fair Poor
In the past year In the past two to five years Six to 10 years ago More than 10 years ago
Male Transgender Female Other
Straight Gay/lesbain Bisexual Other: (please specify)
Less than $15,000 $15,000–$34,999 $35,000–$49,999 $50,000–$74,999 $75,000–$99,999 $100,000 or more
American Indian or Alaska Native Arab or Middle Eastern Asian Black or African American Hispanic or Latino Native Hawaiian or other Pacific Islander White Other: (please specify)