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1
Personal Info
2
Health Info
Name
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First
Last
Date of Birth
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Enter Year
2023
2022
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2020
2019
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1930
Gender
*
Select
Female
Male
Non-binary
Other
Hidden
Date of Birth
MM
1
2
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DD
1
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YYYY
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
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2002
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1999
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1995
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1992
1991
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1982
1981
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1978
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1965
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1963
1962
1961
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1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
What is this person’s ethnicity?
*
American Indian or Alaska Native
Asian
Black or African American
Middle Eastern or North African
Native Hawaiian or Pacific Islander
White
Is this person of Hispanic, Latino, or of Spanish origin?
*
Yes
No
Prefer not to answer
Does this person have any food allergies?
*
Egg
Fish
Milk/Dairy
Peanut
Sesame
Shellfish (e.g., shrimp, crab, lobster)
Soy
Tree Nut (e.g., almonds, cashew, hazelnut)
Wheat
No food allergies
Other
Does this person have any existing health conditions?
*
None
Cancer
Crohn's Disease
Celiac Disease
Diabetes-Type 1
Diabetes-Type 2
Gastrointestinal Disease
Heart Disease
Kidney Disease
Sickle Cell Disease
Other
Other food allergy
Other health conditions
How would you rate the overall health of this person?
*
1 (poor health)
2
3
4
5 (excellent health)
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