Health and Wellness Survey

Question Title

* What is your Gender?

Male

Female

Other

Question Title

* What is your Age?

<14

15-19

20-29

30-39

40-49

50-59

60-69

70+

Question Title

* Please rank the importance of each of the following. Note: only 1 response per column.

	1 Least Important	2	3	4 Important	5	6	7 Most Important
Family	Family 1 Least Important	Family 2	Family 3	Family 4 Important	Family 5	Family 6	Family 7 Most Important
Friends	Friends 1 Least Important	Friends 2	Friends 3	Friends 4 Important	Friends 5	Friends 6	Friends 7 Most Important
God	God 1 Least Important	God 2	God 3	God 4 Important	God 5	God 6	God 7 Most Important
Health	Health 1 Least Important	Health 2	Health 3	Health 4 Important	Health 5	Health 6	Health 7 Most Important
Career	Career 1 Least Important	Career 2	Career 3	Career 4 Important	Career 5	Career 6	Career 7 Most Important
Financial Security	Financial Security 1 Least Important	Financial Security 2	Financial Security 3	Financial Security 4 Important	Financial Security 5	Financial Security 6	Financial Security 7 Most Important
Physical Appearances	Physical Appearances 1 Least Important	Physical Appearances 2	Physical Appearances 3	Physical Appearances 4 Important	Physical Appearances 5	Physical Appearances 6	Physical Appearances 7 Most Important

Other (please specify)

Question Title

* How long would you like to live? (please specify age)

Question Title

* How long do you think you will live? (please specify age)

Question Title

* If there is a significant difference between the above, please explain.

Question Title

* Can you picture your future self?

Yes

No