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*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
Male
*
Female
*
Farm
*
Town <10,000 or Rural Non-Farm
*
Town/City/Suburb 10,000-50,000
*
City/Suburb >50,000
*
City-Central >50,000
*
Hispanic Yes
*
Hispanic No
*
American Indian
*
Asian
*
Black
*
Native Hawaiian or Pacific Islander
*
White
*
Prefer not to say
*
Not Listed
*
*
*
*
*
P/G 1 Release Yes
*
P/G 1 Release No
*
*
P/G 2 Release Yes
*
P/G 2 Release No
*
*
EC Release Yes
*
EC Release No
*
*
*
*
*
*
*
*
*
Active Duty
*
National Guard
*
Reserves
*
Service Status Other
*
*
Insects Allergy Yes
*
Insects Allergy No
*
Dairy Allergy Yes
*
Dairy Allergy No
*
Gluten Allergy Yes
*
Gluten Allergy No
*
Nuts Allergy Yes
*
Nuts Allergy No
*
Other Allergy Yes
*
Other Allergy No
*
*
Acetaminophen Yes
*
Acetaminophen No
*
Antacid Yes
*
Antacid No
*
Antihistamine Pill Yes
*
Antihistamine Pill No
*
Decongestant Yes
*
Decongestant No
*
Dramamine Yes
*
Dramamine No
*
Hydrocortisone Cream Yes
*
Hydrocortisone Cream No
*
Ibuprofen Yes
*
Ibuprofen No
*
Polysporin Yes
*
Polysporin No
*
Asthma Yes
*
Asthma No
*
Fainting Yes
*
Fainting No
*
Glasses/Contacts Yes
*
Glasses/Contacts No
*
Bronchitis Yes
*
Bronchitis No
*
Headaches Yes
*
Headaches No
*
Convulsions Yes
*
Convulsions No
*
Heart Condition Yes
*
Heart Condition No
*
Diabetes Yes
*
Diabetes No
*
Hypoglycemia Yes
*
Hypoglycemia No
*
Ear Infection Yes
*
Ear Infection No
*
Other Conditions Yes
*
Other Conditions No
*
*
*
*
Draw
Type
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*
*
Survey Permission Yes
*
Survey Permission No
*
*
*
Draw
Type
Upload
Choose your signature image
*
Deny Publicity
*
*
*
*
*
Draw
Type
Upload
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*
Draw
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*
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