Please download and review the participant information sheet if you have not already.
"I have read the participant information sheet and I do not have any questions about participation. I voluntarily consent to participate in this study. I understand that future questions I may have about the research or about my rights as a participant will be answered by study staff at 425-602-3306 or neuroresearch@bastyr.edu."
Yes
No
TO SAVE YOUR INFORMATION & RETURN AT A LATER TIME:
Who is completing this survey?
1. Person with Parkinsonism/ Parkinson's disease (PWP)
2. Friend/ caregiver, in the presence of PWP (for instance, if motor symptoms make keyboard use difficult, or if PWP is not comfortable on computer.)
3. Other
Please describe who is completing this form and your relationship to the PWP:
Create a PATIENT RECORD ID:
* must provide value
example: ABCD84
Today M-D-Y
Your date of birth:
* must provide value
Today M-D-Y
Has your name, address or other personal information changed since you last completed the survey?
* must provide value
Yes
No
United States Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Canada Central African Republic Chad Chile China Colombia Comoros Congo - Democratic Republic of the Congo - Republic of the Costa Rica Cote d'Ivoire Croatia Cuba Curacao Cyprus Czechia Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria North Korea Norway Oman Pakistan Palau Palestinian Territories Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South Korea South Sudan Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican Venezuela Vietnam Yemen Zambia Zimbabwe
Country within the United Kingdom
England Northern Ireland Scotland Wales
Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Marianas Islands North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming
Alberta (AB) British Columbia (BC) Manitoba (MB) New Brunswick (NB) Newfoundland and Labrador (NL) Northwest Territories (NT) Nova Scotia (NS) Nunavut (NU) Ontario (ON) Prince Edward Island (PE) Quebec (QC) Saskatchewan (SK) Yukon (YT)
State , province, or region
Have you received a new diagnosis or has your diagnosis or thoughts of your diagnosis changed?
* must provide value
Yes
No
Parkinson's disease/ Idiopathic Parkinson's disease (PD)
Parkinsonism
Multiple system atrophy (MSA)/ Shy-Drager syndrome
Progressive supranuclear palsy (PSP)
Corticobasal degeneration (CBD)
Dementia with Lewy bodies (DLB)
Pick's disease
Olivopontocerebellar atrophy (OPCA)
Other
I don't have a diagnosis but believe I may be at increased risk of parkinsonism
Date of Parkinson's diagnosis?
Today M-D-Y
What is the approximate month, day, and year that you first began having motor symptoms related to PD, even before your diagnosis?
Today M-D-Y
If other, please describe:
Was your diagnosis made by:
Primary care provider / general medicine practitioner
Neurologist, general
Neurologist, movement disorders specialist
Other
If other, who made your diagnosis?
I believe my diagnosis is correct / accurate.
True
False
True
False
Was there a delay in your diagnosis?
Yes
No
What were you originally diagnosed with?
Did people think your symptoms were "all in your head"?
Yes
No
Over the past 6 months, would you say your disease has:
Improved Been stable Worsened
Which stage best represents your disease?
1-sided symptoms only, minimal disability Both sides affected, balance is stable Mild to moderate disability, balance affected Severe disability, able to walk and stand without help Confinement to bed or wheelchair unless aided Don't know
Yes
No
Have you had a clear and dramatic beneficial response to dopaminergic therapy?
Yes, during initial treatment with dopamine (e.g., levodopa), my function returned to near-normal or normal. (Mild changes do not qualify)
No
I have never done a therapeutic trial of dopaminergic therapies (e.g., levodopa).
By which percent does dopamine repletion improve your symptoms?
I can feel my dopaminergic medicines "kick in" and/or "wear off."
True
False
Not applicable / do not take dopamine (e.g., levodopa)
Slowness
* must provide value
Constipation (incomplete bowel empyting)
* must provide value
Walking
* must provide value
Freezing
* must provide value
Falling
* must provide value
Rising from seated position
* must provide value
Dressing, Eating, Grooming
* must provide value
Motivation & Initiative
* must provide value
Handwriting & Typing
* must provide value
Depression (feeling sad, blues)
* must provide value
Loss of Interest
* must provide value
Anxiety
* must provide value
Fatigue
* must provide value
Daytime Sleepiness
* must provide value
Dyskinesia
* must provide value
Tremor
* must provide value
Sense of balance
* must provide value
Control of Body Temperature
* must provide value
Dizzy on standing
* must provide value
Visual disturbance
* must provide value
Insomnia (inability to sleep)
* must provide value
Sleep behavior disorder (e.g. acting out dreams)
* must provide value
Restless Legs- Urge to move legs in order to stop unpleasant sensations
* must provide value
Muscle cramping, pain, or aching
* must provide value
Speech
* must provide value
Drooling
* must provide value
Stooped posture
* must provide value
Memory/ Forgetfulness
* must provide value
Comprehension
* must provide value
Sense of smell
* must provide value
Medication Side Effects
* must provide value
Sexual dysfunction
* must provide value
Urinary symptoms
* must provide value
Hallucinations or Delusions
* must provide value
Nausea
* must provide value
View equation Male
Female
Non-binary
What is your current marital or partnership status?
Married
Divorced
Single
Domestic partnership
Other
Caucasian
Black
Hispanic
Native American
Asian / Pacific Islander
Other
Highest grade level completed:
Less than 8th grade
Grades 9-11
Completed High School/GED
Technical school certification
Associate Degree
Bachelors Degree
Graduate / Professional degree
What is your natural hair color?
Black
Blond
Brown
Red
Other
Please mark box if you have taken any of the following consistently over the past 6 months.
Alpha-Lipoic acid
Coconut oil
Vitamin B12 (methylcobalamin, cyanocobalamin)
Vitamin C
Calcium
Vitamin D
CoQ10
DHEA
Estrogen
Fish Oil
NADH
Gingko biloba
Glutathione, oral
Glutathione, intranasal
Inosine
Iron (Fe)
Lithium, low dose
Marijuana (edible)
Marijuana (inhaled)
Melatonin
Probiotics
Quercetin
Resveratrol
Homocysteine Factors (B6, B12, folic acid, betaine)
Turmeric/ curcumin
5 methyltetrahydrofolate (5-MTHF)
Multivitamin/ Mineral
N-acetyl cysteine (NAC)
Low dose naltrexone
Mucuna
Fava beans
Dance for PD
Tremble Clefs program
Lee Silverman Voice Treatment
High Dose Thiamine (Vitamin B1), Oral
High Dose Thiamine (Vitamin B1), Intramuscular
Lion's Mane mushroom
Other medicinal mushrooms (reishi, cordyceps, chaga, agaricus, etc.)
Testosterone, Intramuscular
Testosterone, Topical
Mannitol
NAD+ (or NR or NMN)
Intravenous micronutrient therapy (e.g., IV vitamins)
Intramuscular micronutrient therapy (e.g., B12 injections)
Intravenous exosome therapy
Red light therapy
Farnesol
What type of oral glutathione do you take?
Capsules or tablets (e.g., Jarrow brand) Liposomal glutathione (e.g., Quicksilver brand)
What type of mucuna do you take?
Please specify what type of mucuna you are taking (brand, dose, etc.).
What type of probiotic do you take?
Are you taking oral NAD+ (pill) or NAD+ via IV?
Oral (pill)
IV
Both
What type/brand of NAD+ are you taking?
Music
View equation On how many of the last seven days did you participate in at least 30 minutes of physical activity?
0 1 2 3 4 5 6 7
What kind of physical activity? (check all that apply)
What "Other" activity do you do?
For how long did you participate?
At what intensity level did you engage, on average, while doing the activity?
1- barely moving
2
3 - increased heart rate, breaking a sweat
4
5- maximum effort
I regularly take live, in-person fitness classes.
True
False
I regularly take online, virtual fitness classes.
True
False
Please select which of the following describes your weight over the last 6 months:
My weight has remained stable
I've gained weight - intentionally
I've gained weight - unintentionally
I've lost weight - intentionally
I've lost weight - unintentionally
This questionnaire is about activities that you may have done in the past 4 weeks. how many TIMES a week you usually did it, and write your response in the space provided.in a typical week you did the activity.Here is an example of how Mrs. Jones would answer question #1: twice a week. She usually spends one hour on Monday with Maria and two hours on Wednesday with Olga. Therefore, the total hours a week that she visits with friends is 3 hours a week.
In a typical week during the past 4 weeks, did you... 1. Visit with friends or family (other than those you live with) ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
2. Go to the senior center ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
4. Attend church or take part in church activities ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
5. Attend other club or group meetings ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
In a typical week during the past 4 weeks, did you... 7. Dance (such as square, folk, line, ballroom)(do not count aerobic dance here) ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
8. Do woodworking, needlework, drawing, or other arts or crafts?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
9. Play golf, carrying or pulling your equipment (count walking time only)?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
10. Play golf, riding a cart (count walking time only)?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
11. Attend a concert, movie, lecture, or sport event ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
12. Play cards, bingo, or board games with other people ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
In a typical week during the past 4 weeks, did you... 13. Shoot pool or billiards ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
14. Play singles tennis (do not count doubles) ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
15. Play doubles tennis (do not count singles) ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
16. Skate (ice, roller, in-line)?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
17. Play a musical instrument?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
19. Do heavy work around the house (such as washing windows, cleaning gutters)?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
In a typical week during the past 4 weeks, did you... 20. Do light work around the house (such as sweeping or vacuuming)?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
21. Do heavy gardening (such as spading, raking)?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
22. Do light gardening (such as watering plants) ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
23. Work on your car, truck, lawn mower or other machinery?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
** Please note: For the following questions about running and walking, include use of a treadmill. Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
25. Walk uphill or hike uphill (count only uphill part)?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
In a typical week during the past 4 weeks, did you... 26. Walk fast or briskly for exercise (do not count walking leisurely or uphill)?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
27. Walk to do errands (such as to/from a store or to take children to school) (count walk time only )?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
28. Walk leisurely for exercise or pleasure?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
29. Ride a bicycle or stationary cycle?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
30. Do other aerobic machines such as rowing, or step machines (do not count treadmill or stationary cycle) ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
31. Do water exercises (do not count other swimming) ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
In a typical week during the past 4 weeks, did you... 32. Swim moderately or fast ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
34. Do stretching or flexibility exercises (do not count yoga or Tai-chi) ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
36. Do aerobics or aerobic dancing ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
37. Do moderate to heavy strength training (such as hand-held weights of more than 5 lbs. , weight machines, or push-ups) ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
In a typical week during the past 4 weeks, did you...
38. Do light strength training (such as hand-held weights of 5 lbs. or less or elastic bands) ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
39. Do general conditioning exercises, such as light calisthenics or chair exercises (do not count strength training) ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
40. Play basketball, soccer, or racquetball (do not count time on sidelines) ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
41. Do other types of physical activity not previously mentioned ?
Yes
No
How many TOTAL hours a week did you usually do it?
Less than 1 hour 1 - 2-1/2 hours 3 - 4-1/2 hours 5 - 6-1/2 hours 7 - 8-1/2 hours 9 or more hours
THANK YOU FOR COMPLETING THE CHAMPS PHYSICAL ACTIVITY QUESTIONS, PLEASE CONTINUE WITH THE REST OF THE SURVEY BELOW.
In general, would you say your health is:...
Excellent
Very good
Good
Fair
Poor
In general, would you say your quality of life is:...
Excellent
Very Good
Good
Fair
Poor
In general, how would you rate your physical health?...
Excellent
Very Good
Good
Fair
Poor
In general, how would you rate your mental health, including your mood and your ability to think?...
Excellent
Very Good
Good
Fair
Poor
In general, how would you rate your satisfaction with your social activities and relationships?...
Excellent
Very Good
Good
Fair
Poor
In general, please rate how well you carry out your usual social activities and roles. (This includes activities at home, at work and in your community, and responsibilities as a parent, child, spouse, employee, friend, etc.)...
Excellent
Very Good
Good
Fair
Poor
To what extent are you able to carry out your everyday physical activities such as walking, climbing stairs, carrying groceries, or moving a chair?...
Completely
Mostly
Moderately
A little
Not at all
How would you rate your pain on average?...
1 No pain
2
3
4
5
6
7
8
9
10 Worst imaginable pain
How would you rate your fatigue on average?...
None
Mild
Moderate
Severe
Very Severe
How often have you been bothered by emotional problems such as feeling anxious, depressed or irritable?...
Never
Rarely
Sometimes
Often
Always
Your ability to have an erection
Very Poor
Poor
Fair
Good
Very Good
PROMIS Sexual - Female
Not at all
A little bit
Somewhat
Quite a bit
Very
How often have you felt like you wanted to have sex?
Never
Rarely
Sometimes
Often
Always
How often did you become lubricated ("wet") during sexual activity or intercourse?
No sexual activity
Almost always or always
Most times (more than half the time)
Sometimes (about half the time)
A few times (less than half the time)
Almost never or never
How difficult has it been for your vagina to get lubricated ("wet") when you wanted it to?
Have not tried to get lubricated in the past 30 days
Not at all
A little bit
Somewhat
Quite a bit
Very
During the past month, what time have you usually gone to bed at night?
During the past month, how long (in minutes) has it usually taken you to fall asleep each night?
During the past month, what time have you usually gotten up in the morning? (HH:MM)
Now H:M
During the past month, how many hours of actual sleep did you get a night? (may be different than the number of hours you spent in bed)
During the past month, how would you rate your sleep quality overall?
Very Good
Fairly Good
Fairly Bad
Very Bad
During the past month, how much of a problem has it been for you to keep up enough enthusiasm to get things done?
No problem at all
Only a very slight problem
Somewhat of a problem
A very big problem
Do you have a bed partner or room mate?
No bed partner or room mate
Partner/room mate in other room
Partner in same room, but not same bed
Partner in same bed
Have you lost weight recently without trying?
No
Yes
Unsure
How much weight have you lost?
1-5 kg (2 - 11 lbs)
6-10 kg (13 - 22 lbs)
11-15 kg (24 - 33 lbs)
> 15 kg (>33 lbs)
MAIA: Noticing -
View equation MAIA: Not-Distracting -
View equation MAIA: Not-Worrying -
View equation MAIA: Attention Regulation -
View equation MAIA: Emotional Awareness -
View equation MAIA: Self-Regulation -
View equation MAIA: Body Listening -
View equation MAIA: Trusting -
View equation
Factor I: Relating to Others (out of 30)
View equation Factor II: New Possibilities (out of 25)
View equation Factor III: Personal Strength (out of 20)
View equation Factor IV: Spiritual Change (out of 5)
View equation Factor V: Appreciation of Life (out of 15)
View equation
Gratitude Questionnaire Total
View equation Do you NOW smoke cigarettes every day, some days, or not at all?
Every day Some days Not at all Don't know
How old were you when you FIRST started to smoke fairly regularly?
Have you smoked at least 100 cigarettes in your ENTIRE LIFE?
Yes
No
How long has it been since you quit smoking cigarettes? (enter number here and unit of time below)
How long has it been since you quit smoking cigarettes? (Time period)
Days
Weeks
Months
Years
Don't know
On the average, how many cigarettes do you now smoke a day?
On how many of the PAST 30 DAYS did you smoke a cigarette?
On the average, when you smoked during the PAST 30 DAYS, about how many cigarettes did you smoke a day?
During the PAST 12 MONTHS, have you stopped smoking for more than one day BECAUSE YOU WERE TRYING TO QUIT SMOKING?
Yes No Don't know
To the best of your ability, please describe the jobs you have held, the work required during your employment, and any potential environmental exposures encountered as part of your work?
I eat most meals at home.
True
False
True
False
I sometimes cook with an air fryer.
True
False
How many times do you use an air fryer per month?
I routinely prepare meals for others.
True
False
It is difficult to afford groceries.
True
False
I find it difficult to afford healthy food.
True
False
I buy food from local farmers (co-op, farmer's markets).
True
False
I try to eat organically grown foods when possible.
True
False
True
False
True
False
True
False
True
False
True
False
I avoid artificial sweeteners.
True
False
True
False
I avoid artificial colors, flavors, etc.
True
False
True
False
True
False
True
False
True
False