H1N1 Survey

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1. Please choose your sex

Please choose your sex Male

Female

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2. Please indicate your age

	My Age Range is
My age is:	Please indicate your age My age is: My Age Range is

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3. In the past 5 years (including 2009) did you get the seasonal flu shot and if so which years? Check all that apply.

In the past 5 years (including 2009) did you get the seasonal flu shot and if so which years? Check all that apply. No	Plan to get it this year	Yes 2009	yes 2008	Yes 2007	Yes 2006	Yes 2005	Yes - not sure which years	Not sure
Othr comments

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4. In the past 5 years did you get the flu and if so which years? Check all that apply.

In the past 5 years did you get the flu and if so which years? Check all that apply. No

Had a bad cold but don't know if it was the flu

Not sure

Yes but not sure which year

Yes in 2008

Yes in 2007

Yes in 2006

Yes in 2005

Yes in 2004

Other comments

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5. Do you have any of the following conditions? (check all that apply)

Do you have any of the following conditions? (check all that apply) Asthma

Lupus/arthritis

Diabetes

Emphysema

heart disease

Pregnant

Cancer

HIV/Aids

None of the above

Other - Please describe

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6. Do you smoke or live in a house where someone else smokes?

Do you smoke or live in a house where someone else smokes? Yes - I currently smoke

Yes - I live in a house where someone else smokes

No - I do not smoke or live in a house where someone else smokes

No - I do not currently smoke, but have smoked in the past

Other comment

7. Do you currently take medication or get treatment for a chronic condition or serious medical condition such as cancer (i.e., high cholesterol, high blood pressure or medication for the conditions listed above) ? Please describe medication. If you are not taking a medication, please make an X or write "No" in the box for "No".

Do you currently take medication or get treatment for a chronic condition or serious medical condition such as cancer (i.e., high cholesterol, high blood pressure or medication for the conditions listed above) ? Please describe medication. If you are not taking a medication, please make an X or write "No" in the box for "No". Yes
No
Other

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8. Have you had the H1N1 flu?

Have you had the H1N1 flu? Had the seasonal flu

Yes, had some sort of flu that I suspect was H1N1

Yes (Definitly diagnosed with H1N1)

No

Was ill but don't know what it was

Had some sort of flu plus pneumonia.

Don’t know

Other comments

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9. Did you get the H1N1 vaccine or are you planning to get the vaccine?

Did you get the H1N1 vaccine or are you planning to get the vaccine? Yes, already was vaccinated

Not sure

Yes, plan to get vaccinated

No, I did not get and do not plan to get the H1N1 vaccine

Other comments

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10. Did you experience any of the side effects of the vaccine?

Did you experience any of the side effects of the vaccine? No

Muscle soreness or weakness

Not applicable

Soreness at the injection site

Guillain Barre Syndrome

Allergic reaction or shock

Cold/Flu like symptoms

Other (please describe)

11. US RESIDENTS:

US RESIDENTS: State:
ZIP/Postal Code:

12. NON-US RESIDENTS:

NON-US RESIDENTS: State/Province
ZIP/Postal Code:
Country:

13. Email address (OPTIONAL). We would like to get back to you to find out if you contracted the flu and to share survey results. We will never pass along your email to anyone. Otherwise check our website www.flutruth.wordpress.com for this information.

Email address (OPTIONAL). We would like to get back to you to find out if you contracted the flu and to share survey results. We will never pass along your email to anyone. Otherwise check our website www.flutruth.wordpress.com for this information. Email Address: (optional)

14. Do you have any additional comments, such as additional questions you would like us to ask or information you believe we should have asked about??

Do you have any additional comments, such as additional questions you would like us to ask or information you believe we should have asked about??

H1N1
Exit this survey

1. H1N1 SURVEY

*
1. Please choose your sex

*
2. Please indicate your age

*
3. In the past 5 years (including 2009) did you get the seasonal flu shot and if so which years? Check all that apply.

*
4. In the past 5 years did you get the flu and if so which years? Check all that apply.

*
5. Do you have any of the following conditions? (check all that apply)

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6. Do you smoke or live in a house where someone else smokes?

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8. Have you had the H1N1 flu?

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9. Did you get the H1N1 vaccine or are you planning to get the vaccine?

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10. Did you experience any of the side effects of the vaccine?

11. US RESIDENTS:

12. NON-US RESIDENTS:

13. Email address (OPTIONAL). We would like to get back to you to find out if you contracted the flu and to share survey results. We will never pass along your email to anyone. Otherwise check our website www.flutruth.wordpress.com for this information.

14. Do you have any additional comments, such as additional questions you would like us to ask or information you believe we should have asked about??

H1N1Exit this survey

1. H1N1 SURVEY

*1. Please choose your sex

*2. Please indicate your age

*3. In the past 5 years (including 2009) did you get the seasonal flu shot and if so which years? Check all that apply.

*4. In the past 5 years did you get the flu and if so which years? Check all that apply.

*5. Do you have any of the following conditions? (check all that apply)

*6. Do you smoke or live in a house where someone else smokes?

*8. Have you had the H1N1 flu?

*9. Did you get the H1N1 vaccine or are you planning to get the vaccine?

*10. Did you experience any of the side effects of the vaccine?

11. US RESIDENTS:

12. NON-US RESIDENTS:

13. Email address (OPTIONAL). We would like to get back to you to find out if you contracted the flu and to share survey results. We will never pass along your email to anyone. Otherwise check our website www.flutruth.wordpress.com for this information.

14. Do you have any additional comments, such as additional questions you would like us to ask or information you believe we should have asked about??

H1N1
Exit this survey

*
1. Please choose your sex

*
2. Please indicate your age

*
3. In the past 5 years (including 2009) did you get the seasonal flu shot and if so which years? Check all that apply.

*
4. In the past 5 years did you get the flu and if so which years? Check all that apply.

*
5. Do you have any of the following conditions? (check all that apply)

*
6. Do you smoke or live in a house where someone else smokes?

*
8. Have you had the H1N1 flu?

*
9. Did you get the H1N1 vaccine or are you planning to get the vaccine?

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10. Did you experience any of the side effects of the vaccine?