First name
Last name
Email		This email must be exclusively yours.  No two participants can use the same email address.
Telephone number:		Include area code for the United States and Canada.  Other countries include country code, area code and a number.
Skype ID		Optional for IM, voice and video communication.
Marital status	Please chose one Single New relationship Long-term-relationship Married
Are you a caregiver	Please select Yes No	Are you taking care of another person(s) or dependants?  Parents, children, friend, other family member?
Are you being taken care of by others?	Please select Yes No	Does other person take care of you because of your health condition?
Education	Chose one Elementary school High school (incomplete) High school graduate College (incomplete) College graduate Postgraduate
Health problem 1	how long months	I.e. migraine, high blood pressure, CFS, endometriosis, enlarged prostate, etc... and how long in months
Health problem 2	how long months
Health problem 3	how long months
Health problem 4	how long months
Health problem 5	how long months
Health problem 6	how long months	If more health problems write them in the comment box below
Medication 1	for
Medication 2	for
Medication 3	for
Medication 4	for
Medication 5	for
Medication 6	for	If taking more than 6 medications, please write them and what they are for in the comment box below.
Your personality	Chose one Optimist Realist Pessimist Entitled Depressed Want to help others Warm, inviting Cold Appreciative Selfcenterd	What others are saying about you?
Do you laugh	Chose one Always Frequently Seldomly Never or almost never
Do you exercise	Chose one More than 3x/week 3x/week Seldomly Never
Other comments and information