Surveys 2015 December D Demo for Doctor Mark

Demo for Doctor Mark

0%

Exit Survey

Hello: You are invited to participate in our survey [Project Description Here]. In this survey, approximately [Approximate Respondents] people will be asked to complete a survey that asks questions about [General Survey Process]. It will take approximately [Approximate Time] minutes to complete the questionnaire. Your participation in this study is completely voluntary. There are no foreseeable risks associated with this project. However, if you feel uncomfortable answering any questions, you can withdraw from the survey at any point. It is very important for us to learn your opinions. Your survey responses will be strictly confidential and data from this research will be reported only in the aggregate. Your information will be coded and will remain confidential. If you have questions at any time about the survey or the procedures, you may contact [Name of Survey Researcher] at [Phone Number] or by email at the email address specified below. Thank you very much for your time and support. Please start with the survey now by clicking on the Continue button below.  I Agree       What is your gender?   Male   Female       Have you ever had an injury to this area?   HEAD   NECK   UPPER BACK   UPPER BACK   UPPER LIMBS   SHOULDER   UPPER ARM   ELBOW   FORE ARM   WRIST   HANDS   LOWER LIMBS   PELVIS   HIPS   THIGH   KNEE   LOWER LEG   ANKLE   FEET   Other injuries, please mention-         Injury Site for -- Select --RightLeftBilateral       Injury Side -- Select --AbdomenAnkleCervical SpineChestElbowFaceFootForearmGroinHandHeadHip/Pelvis/ButtockKneeLower Leg/AchillesLumbosacral SpineMedicalShoulderThigh AnteriorThich PosteriorThoracic SpineUpper ArmWrist       Injury Site -- Select --RightLeftBilateral       Injury Side -- Select --AbdomenAnkleCervical SpineChestElbowFaceFootForearmGroinHandHeadHip/Pelvis/ButtockKneeLower Leg/AchillesLumbosacral SpineMedicalShoulderThigh AnteriorThich PosteriorThoracic SpineUpper ArmWrist       1. Do you take any medications or supplements?   Yes   No       Option 1 Option 2 Option 3       Name of medication / supplement     How likely are you to doze off or fall asleep in the following situations? You should rate your chances of dozing off, not just feeling tired. Even if you have not done some of these things recently try to determine how they would have affected you. For each situation, decide whether or not you would have: Write down the number corresponding to your choice in the right hand column. Total your score below. No chance of dozing Slight chance of dozing Moderate chance of dozing High chance of dozing Sitting and reading Watching TV Sitting inactive in a public place       Your total score: 0.0       Please sign here Clear

  Loading...

  Loading...