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Surveys
2015
December
E
Effects of smoking on Alzheimer's and Parkinson's
Effects of smoking on Alzheimer's and Parkinson's
0%
Exit Survey
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?
-- Select --
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
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
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