Qualtrics Survey | Qualtrics Experience Management

Please answer all questions to the best of your knowledge. If you would like to review the purpose of the study, please go to ALLY Study Webpage or email us at mesalab@csun.edu.

Enter your first and last name below.

First Name

Last Name

Select your sex at birth.

Male
Female

Select your preferred pronouns

Enter your Date of Birth

Enter your Date of Birth<br>
	Month	Day	Year



Please Select:	Month - Please Select:	Day - Please Select:	Year - Please Select:

Tell us your age (as of today)

Tell us the race and ethnicity of yourself and your parents (if known).

Select all that apply. If you select "Other", then enter additional details in the space below. Note, you may report more than one group.

If unknown, please leave blank.

Tell us the race and ethnicity of yourself and your parents (if known).

Select all that apply. If you select "Other", then enter additional details in the space below. Note, you may report more than one group.

If unknown, please leave blank.
WHITE
	Yourself	Mother	Father
German	Yourself	Mother	Father
Irish	Yourself	Mother	Father
English	Yourself	Mother	Father
Italian	Yourself	Mother	Father
Polish	Yourself	Mother	Father
French	Yourself	Mother	Father
Enter, for example, Scottish, Norwegian, Dutch, etc.	Yourself	Mother	Father
	Yourself	Mother	Father
HISPANIC OR LATINO
Mexican or Mexican American	Yourself	Mother	Father
Puerto Rican	Yourself	Mother	Father
Cuban	Yourself	Mother	Father
Salvadoran	Yourself	Mother	Father
Dominican	Yourself	Mother	Father
Colombian	Yourself	Mother	Father
Enter, for example, Guatemalan, Ecuadorian, etc.	Yourself	Mother	Father
	Yourself	Mother	Father
BLACK OF AFRICAN AMERICAN
African American	Yourself	Mother	Father
Jamaican	Yourself	Mother	Father
Haitian	Yourself	Mother	Father
Nigerian	Yourself	Mother	Father
Ethiopian	Yourself	Mother	Father
Somali	Yourself	Mother	Father
Enter, for example, Ghanian, South African, Barbadian, etc.	Yourself	Mother	Father
	Yourself	Mother	Father
ASIAN
Chinese	Yourself	Mother	Father
Filipino	Yourself	Mother	Father
Asian Indian	Yourself	Mother	Father
Viatnamese	Yourself	Mother	Father
Korean	Yourself	Mother	Father
Japanese	Yourself	Mother	Father
Enter, for example, Pakistani, Cambodian, Hmong, etc.	Yourself	Mother	Father
	Yourself	Mother	Father
MIDDLE EASTERN OR NORTH AFRICAN
Lebanese	Yourself	Mother	Father
Iranian	Yourself	Mother	Father
Egyptian	Yourself	Mother	Father
Syrian	Yourself	Mother	Father
Moroccan	Yourself	Mother	Father
Israeli	Yourself	Mother	Father
Enter, for example, Algerian, Iraqi, Kurdish, etc.	Yourself	Mother	Father
	Yourself	Mother	Father
NATIVE HAWAIIAN OR PACIFIC ISLANDER
Native Hawaiian	Yourself	Mother	Father
Samoan	Yourself	Mother	Father
Chamorro	Yourself	Mother	Father
Tongan	Yourself	Mother	Father
Fijian	Yourself	Mother	Father
Marshallese	Yourself	Mother	Father
Enter, for example, Palauan, Tahitian, Chuukese, etc.	Yourself	Mother	Father
	Yourself	Mother	Father
AMERICAN INDIAN OR ALASKA NATIVE
Enter, for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Tribal Government, Tlingit, etc.	Yourself	Mother	Father
OTHER RACE
Some other race - Please write in race/ethnicity	Yourself	Mother	Father

List ALL BIRTHPLACES (Country of Birth) for each person below:

Enter the zip code of your current residence?

Zip Code:

Provide your estimated Weight and Height: (if you are unsure, please enter a close estimate)

Provide your estimated Weight and Height: (if you are unsure, please enter a close estimate)<br>
	Weight	Height


	Pounds (lbs)	Feet (5')	Inches (2")
Enter the following:

*Now we would like to know a little about your health and any medications:

Do you have asthma?

No
Yes

If yes, which medication:

Name/Type

Dosage

When Started

Have you had any major illness/medical condition since birth?

No
Yes, then list:

Are you currently taking any medication(s):

No
Yes

If yes, then list and for what condition

List medications

What condition

What is your primary language spoken at home?