$200 LA Technology & Fitness Study Survey

1.Contact Info(Required.)

Full Name:

Email:

Phone:

Age:

Gender:

City, State you live in:

DOB:

2.Which of the following best describes your ethnicity?(Required.)

4.What is your height without shoes on?(Required.)

5.What is your approximate weight (in lbs)? Please enter the number only without words like "lb" or "pounds".(Required.)

8.Please indicate which, if any, of the following apply to you AND have worsened within the past 3 months.(Required.)

None of these apply to me and have worsened in the past 3 months

Have diabetes

Have renal disease

Have atherosclerotic coronary vascular disease (myocardial infraction, coronary artery bypass surgery, pacemaker, angioplasty, stent)

9.Have you been diagnosed with hypertension?(Required.)

No

Yes and my standard daytime blood pressure is:

10.Have you previously or do you currently have any of the following health conditions?(Required.)

None of these apply to me

Loss of balance because of dizziness or ever losing consciousness

Difficulty breathing when lying down

Increasing shortness of breath with performing usual activities or exercise

Forceful or fast heartbeat

Ankle, foot or leg swelling

Recurrent pain, cramping or ache in the legs with activity such as walking that goes away with a few minutes of rest

Pain in the left side of the chest, jaw, or neck when you do physical activity

Currently or previously have chest pain when not doing physical activity

$200 LA Technology & Fitness Study