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The purpose of this survey is to see if there is a connection between cigarette smoking, Alzheimer's disease and Parkinson's disease. Your survey responses will be strictly confidential. I realize that a patient in progressed stages of Alzheimer's or Parkinson's disease aren't capable of taking this survey. If you know someone with one of these diseases and are taking the survey for them, please indicate so. If you are taking the survey for someone else and you aren't sure of the answer, please choose other and indicate what you believe the answer to be. If you have questions at any time about the survey or the procedures, you may contact Makayla Farrell at 518-291-0377 or by email at [email protected]
Thank you very much for your time.
 
 
 
Are you taking this survey for yourself, a family member, patient or as a caregiver?
 
Myself
 
Family Member
 
Patient
 
Someone I Take Care of
 
Other
 
 
 
 
Are you male or female?
 
Male
 
Female
 
Other (Please explain)
 
 
 
 
How old are you?
   
 
 
 
What country do you live in?
 
United States
 
Canada
 
Australia
 
Other
 
 
 
 
If you do live in the US, what state do you live in?
 
 
 
Have you always lived in that state? If not, please choose any states that you lived in for five years or more.
 
Alabama
 
Alaska
 
Arizona
 
Arkansas
 
California
 
Colorado
 
Connecticut
 
Delaware
 
Florida
 
Georgia
 
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 Dakota
 
Ohio
 
Oklahoma
 
Oregon
 
Pennsylvania Rhode Island
 
South Carolina
 
South Dakota
 
Tennessee
 
Texas
 
Utah
 
Vermont
 
Virginia
 
Washington
 
West Virginia
 
Wisconsin
 
Wyoming

 
 
 
Are you currently a smoker?
 
yes
 
no
 
 
 
How long have you been a smoker?
   
 
 
 
How often do you conduct surveys?
 
Weekly
 
Monthly
 
Quarterly
 
Annually