Health Research 03/06/14 Question Title * 1. What is your contact information? Name Phone Number Address and City Email Address Question Title * 2. What is your age? 18-24 25-29 30-34 35-40 41-50 51-60 61 years or older Question Title * 3. Have you been diagnosed with any of the following? Autoimmune Disease Primary Immunodeficiency (PI) Human Immunodeficiency Virus (HIV) None of the Above Question Title * 4. What is the highest level of education you have had the opportunity to complete? Some High School Graduated High School Some College Graduated College Some Post-Gradate Work Post-Graduate Degree Done