SoloHealth: Pre-Study Questionnaire

What is your gender?

Male

Female

Other

What is your age?

Do you already have an account set up with SoloHealth's kiosk?

Yes

No

How would you describe your overall health? Would you say you are:

In great physical health.

In good physical health. No serious illness/disability.

Mildly physically impaired. Corrective illness/disability.

Slightly physically impaired. Substantial medical treatment.

Physically impaired. Extensive medical treatment.

Do you have health insurance?

Yes

No

Not sure

Are you currently employed?

Yes

No

How many times a year do you visit the doctor?

What types of credit cards do you have (Select all that apply)?

Select all family medical history conditions that apply:

Do you have any particular medical/health concerns?