1) Your Profile Info

First Name *

Last Name *

Email *

Confirm Email *

Gender *
---MaleFemale

Birth Year *
---20112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926

Country *
---CanadaUSA

Please select any illness and/or condition you have experienced *
AcneAlzheimersAsthmaCancerDepressionDiabetes - Type IIHeart DiseaseHemorrhoidsHigh Blood PressureHIV/AIDSInsomniaLeukemiaParalysisPsoriasis/EczemaTumorVertigoAllergiesArthritisAttention Deficit DisorderCOPDDiabetes - Type IHeart AttackHemophiliaHepatitisHigh CholesterolIBDLactose IntoleranceLiver DiseaseParkinson’sStrokeUlcerNone

2) In order to classify potential candidates for future research, we have a few questions for you:

Your current martial status? *
---Single, never marriedMarried or common lawSeparated or divorced or widowed

What is the highest level of education you have completed?*
---Some high school or lessGraduated high schoolPost-secondary technical trainingSome college or universityCollege diplomaBachelor DegreeMaster DegreePhD

Which of the following best describes your current employment status?*
---Working full-timeWorking part-timeSelf-employedUnemployedStudentHomemakerSemi-retiredRetired

If you answered that you are employed, what is your occupation?

What is the approximate income of your household?*
---Under $20,000$20,000-$39,999$40,000-$59,999$60,000-$79,999$80,000-$99,999$100,000-$149,999$150,000 or more

Which of the following best describes your household composition?*
---Single AdultCoupleFamily with children over 18Family with children under 18

Which of the following best describes your ethnic background?*
---Caucasian/WhiteChineseFilipinoSouth Asian (East Indian, Indo-Canadian)Middle EasternAfrican CanadianAfrican AmericanHispanic/LatinoFirst NationsOthers AsianOthers

Do you currently smoke cigarettes *
---YesNo

Do you own any pets? *
---DogCatOtherNone of the above

How many vehicles does your household own or lease?*
---01234+

What city do you live in? *

What are the first three digits of your postal code?*

Telephone*