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 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?

What city/town do you spend most weekdays (for work, school, etc.)?

Do you have allergies?

Do you have hay fever?

Do you have asthma?

If yes, do you use a daily medication for your asthma?

Do you smoke cigarettes?

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?

Have you seen a healthcare provider in the last year other than for a regular check-up?

Do you have heart disease?

Do you have high blood pressure?

Have you ever had a stroke or mini stroke (TIA)?

Do you have diabetes?

Are you immunocompromised?

Do you have orthopedic limitations?

Do you have thyroid disease?

Do you have any other chronic illnesses?

If yes please list?

Do you take any prescriptions other than birth control?

If yes please list?

Have you had the flu in the past 2 years?

Did you receive a seasonal flu vaccine in the past 2 years?

Did you receive an H1N1 vaccine?

Are you currently in any other research studies?

How long may we keep your information on record?