1. H1N1 SURVEY

* 1. Please choose your sex

* 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?

* 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".

* 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??

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