Section 1: Demographics and Occupation
1. Age
o Under 18
o 18-24
o 25-34
o 35-44
o 45-54
o 55-64
o 65+
2. Gender
o Male
o Female
o Non-binary
o Prefer not to say
3. Occupation
o Student
o Employed (Full-time)
o Employed (Part-time)
o Self-employed
o Unemployed
o Retired
o Other
4. Work Hours per Week
o 0-10 hours
o 11-20 hours
o 21-30 hours
o 31-40 hours
o 41-50 hours
o 51+ hours
5. Nature of Work
o Physical
o Mental
o Both
o Not applicable
6. Education Level
o High School or below
o Some College
o Bachelor’s Degree
o Master’s Degree
o Doctoral/PhD
7. Marital Status
o Single
o Married
o Divorced
o Widowed
o Other (Please specify)
Section 2: Activity Levels
8. How many hours per week do you engage in physical activities?
o None
o 1-3 hours
o 4-6 hours
o 7-10 hours
o 10+ hours
9. What type of physical activities do you engage in? (Choose all that apply)
o Cardio (e.g., running, cycling)
o Strength Training (e.g., weightlifting)
o Yoga/Pilates
o Sports (e.g., football, basketball)
o Walking/Stretching
o Other (Please specify)
Section 3: Sleep Quality
10. How many hours do you sleep on average per night?
Less than 4 hours
4-5 hours
6-7 hours
8 hours
9+ hours
11. Do you experience any sleep disturbances?
Yes, insomnia
Yes, sleep apnea
Yes, other disturbances (Please specify)
No disturbances
12. Rate your overall sleep quality on a scale of 1-5:
1 - Poor
2 - Fair
3 - Good
4 - Very Good
5 - Excellent
Section 4: Chronic Illness History
13. Do you have any chronic illnesses?
Yes
No
14. If yes, please specify your chronic illness(es):
Diabetes
Hypertension
Asthma
Arthritis
Heart Disease
Other (Please specify)
Section 5: Nutrition and Diet
15. How would you describe your diet?
Fairly Healthy
Extremely Healthy
Unhealthy
16. How often do you consume fast food or processed food?
Never
Once a week
2-3 times a week
4-5 times a week
Daily
17. Do you take any dietary supplements?
Yes, regularly
Yes, occasionally
No
Section 6: Mental Health and Lifestyle
18. How would you rate your stress levels?
Low
Medium
High
19. Do you consume alcohol?
Yes, regularly
Yes, occasionally
No
20. Do you smoke?
Yes, regularly
Yes, occasionally
No
Section 7: Medical History and Medication
21. Have you undergone any major surgeries or medical treatments in the past 5 years?
Yes
No
22. Are you currently on any long-term medication?
Yes
No
Section 8: Social Behavior
23. How often do you engage in social activities?
Weekly
Monthly
Rarely
Section 9: Genetic Factors
24. Do you have a family history of any chronic illnesses?
Yes
No
25. If yes, please specify the chronic illness(es):
Diabetes
Hypertension
Cancer
Heart Disease
Stroke
Other (Please specify)
Section 10: Environmental Factors
26. Where do you live?
Urban Area
Rural Area
27. Are you exposed to high levels of pollution or poor air quality in your environment?
Yes, regularly
Yes, occasionally
No
Section 11: Work-Related Stress
28. How would you rate your work-related stress levels?
Low
Medium
High
Section 12: Additional Health Information
1. Have you ever been diagnosed with any of the following conditions? (Select all that apply)
o Hypertension (High Blood Pressure)
o Diabetes
o Heart Disease
o Stroke
o Cancer
o Kidney Disease
o Asthma
o Autoimmune Diseases (e.g., lupus, rheumatoid arthritis)
o Digestive Disorders (e.g., IBS, Crohn’s disease)
o Mental Health Disorders (e.g., depression, anxiety, bipolar)
o Other (Please specify)
2. Do you currently manage any of the following chronic health conditions? (Select all that
apply)
o Hypertension (High Blood Pressure)
o Diabetes
o Obesity
o Asthma
o High Cholesterol
o Depression/Anxiety
o Chronic Pain
o Sleep Disorders (e.g., insomnia, sleep apnea)
o Other (Please specify)
3. How often do you experience symptoms of the following conditions?
o Heart Disease
Never
Occasionally (once a month or less)
Frequently (1-3 times a week)
Almost daily
o Asthma
Never
Occasionally (once a month or less)
Frequently (1-3 times a week)
Almost daily
o High Blood Pressure
Never
Occasionally (once a month or less)
Frequently (1-3 times a week)
Almost daily
4. Have you ever been hospitalized for any chronic illness?
o Yes
o No
5. Have you ever had a major surgery related to any health condition? (e.g., heart surgery,
cancer surgery, organ transplant)
o Yes
o No
6. Do you regularly monitor your health (e.g., blood pressure, blood sugar levels,
cholesterol)?
o Yes, regularly
o Occasionally
o No
7. If you have any existing conditions, do you actively follow a treatment or management
plan prescribed by a healthcare provider?
o Yes, strictly
o Yes, sometimes
o No
Section 13: Lifestyle and Risk Factors
8. How often do you engage in activities that are known to improve heart health (e.g.,
cardiovascular exercises, healthy eating)?
o Always
o Frequently
o Occasionally
o Never
9. Do you experience frequent headaches or migraines?
o Yes, regularly
o Occasionally
o No
10. How often do you feel fatigued or overly tired during the day?
o Never
o Occasionally
o Frequently
o Always
11. Do you follow a specific dietary regimen due to a health condition (e.g., low-sodium for
hypertension, low-sugar for diabetes)?
o Yes
o No
12. How often do you experience digestive issues (e.g., bloating, acid reflux, constipation)?
o Never
o Occasionally
o Frequently
o Always
Section 14: Perceived Health and Illness Prediction
13. In your opinion, how healthy do you consider yourself to be overall?
o Very Healthy
o Healthy
o Average
o Unhealthy
o Very Unhealthy
14. Are you concerned about developing any specific chronic illness in the future?
o Yes
o No
o I don’t know
15. Do you believe there is a family history of chronic illnesses affecting your health?
o Yes
o No
o Not sure