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  2. 2013
  3. August
  4. H
  5. Health Appraisal Questionnaire
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Questions marked with an * are required Exit Survey
 
 
What is your gender?
 
Male
 
Female
 
 
 
* First Name : 
* Last Name : 
* Address 1 : 
   Address 2 : 
* City : 
* State : 
* Zip : 
* Phone : 
* Email Address : 
 
 
 
What is your age?
   
 
 
 
Do you have a history of exposure to chemicals (e..g as a child, in the work place)?
 
Yes
 
No
 
 
 
If yes, what sort of chemicals and how often have you been exposed to this?
   
 
 
 
How itchy is your skin condition?
Unbearably itchy
Very itchy
Itchy
Sometimes itchy
Not itchy
 
 
How often do you eat;
Never 1 to 3 times a week 4 to 6 times a week Daily Several times a day
Green vegetables?
Gluten containing foods such as bread, cakes, biscuits, crackers?
Fish and seafood?
Meat?
 
 
 
What do you do most days (i.e work or stay at home)?
   
 
 
 
Are you exposed to chemicals (e.g. at work, home, gardening, a hobby)?
 
Yes
 
Occasionally
 
No