Info Study Subject Questionnaire I have read the disclaimer and I would like to submit the questionnaire. What is your name? What is your age? What is your height? What is your weight? What is your email address? What is your phone number (area code + number)? When is a good time to reach you weekdays between 8 AM and 5 PM? Are you available sometime during weekday hours? YesNo What city/town do you spend most weekdays (for work, school, etc.)? Do you have allergies? NoYes Do you have hay fever? NoYes Do you have asthma? NoYes If yes, do you use a daily medication for your asthma? NoYes Do you smoke cigarettes? NoYes If yes, how many cigarettes a day? For how many years have you smoked? Are you pregnant, nursing a baby or trying to get pregnant within the next year? NoYes Have you seen a healthcare provider in the last year other than for a regular check-up? NoYes Do you have heart disease? NoYes Do you have high blood pressure? NoYes Have you ever had a stroke or mini stroke (TIA)? NoYes Do you have diabetes? NoYes Are you immunocompromised? NoYes Do you have orthopedic limitations? NoYes Do you have thyroid disease? NoYes Do you have any other chronic illnesses? NoYes If yes please list? Do you take any prescriptions other than birth control? NoYes If yes please list? Have you had the flu in the past 2 years? NoYesDon't remember Did you receive a seasonal flu vaccine in the past 2 years? NoYesDon't remember Did you receive an H1N1 vaccine? NoYes Are you currently in any other research studies? NoYes How long may we keep your information on record? 1 month1 yearIndefinitely
