Personal Profile

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Welcome to the optional Personal Profile. This questionnaire will help our team of specialists better evaluate your test results and respond to your questions. Once you fill out this profile, it will be included automatically whenever you request information by e-mail from one of our specialists.



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Personal Background

1. Gender	Male	Female
2. Date of Birth  /  / 

3. What is the highest education you have completed?

Less than High School
High School Diploma
Technical school beyond 12th Grade
Some College, Associate Degree
College Degree (BA or BS)
Some Graduate School/Master's
Professional Degree(s): Ph.D., JD, MD

4. People sometimes identify themselves by race and color. What category below do you apply to yourself?

American Indian or Alaskan Native
Asian
Black, African American
Hispanic
Caucasian, White
Other

5. What is your current marital status ?

Married
Partnered/Live with significant other
Never Married
Divorced
Separated
Widowed

6. How many children do you have living at home?

0 1 2 3 4 5 6 7

7. What is your annual income from salary, wages or consulting?

Under $10,000
$10,000 - $29,000
$30,000 - $39,000
$40,000 - $49,000
$50,000 - $79,000
$80,000 or more

8. What is your managerial status?

Not a Manager
Entry Level Manager
Middle Manager
Senior Manager/Executive

9. What is your usual occupation or job title?

10. Describe the type of work you do.

11. How many hours per week do you usually work?

Less than 25 hrs.
26 - 35 hrs
36 - 40 hrs
41 - 50 hrs
51 - 59 hrs
60 or more

12. Years at current employer:

13. Years in this occupation or field:

14. How would you describe your current health?

Excellent  Good   Fair  Poor

15. How much distress are you currently experiencing in your life ?

Great deal 	 Some   Not Much   None

16. In your opinion, what is the single greatest source of stress for you right now?
Please specify:

17. How many times have you been to the doctor (MD) in the last twelve months?


    None     1-2     3-5     6-10    11-15    16+

18. How many times have you or a family member been treated in an emergency room in the last twelve months?


    None 1     2-3   4-6   7-9   10+ 

19. How many days have you been absent because of injury in the last 12 months?

20a. Were you injured while on the job?

	Yes No

20b. If yes, what kind of injury? Please explain:

21. Did the injury result in a disability at any time?

	Yes No

22.How many days have you been absent from work because of sickness in the last 12 months?

23. My blood pressure is:

Low (less than 99/60)
Healthy (100/60 to 150/90)
High (150/90+)
Don't know my blood pressure

24. My blood cholesterol level is:

Healthy (less than 200 mg/dL)
Borderline to High (201-239 mg/dL)
High (240 + mg/dL)
Don't know my cholesterol level

25. How many cigarettes do you smoke per day?

26. For how many years have you been smoking or how many years did you smoke?

27. How often do you drink any kind of alcoholic drink? This includes wine, beer and liquor.

Once a day or more
Nearly every day 
Three or four times a week
Once or twice a week
Two or three times a month
About once a month
Rarely or Never

28. Was there ever a time in your life when you drank five or more alcoholic drinks in a sitting as often as once a week ?

Yes No

29. How true is each of the following statements for you?

A. I am satisfied with the level of my work performance.

Very true Somewhat A little Not at all

b. This company has a strong emphasis on quality work.

Very true Somewhat A little Not at all

c. Resources are limited. You have to fight to get things.

Very true Somewhat A little Not at all

d. In my work team, I am involved in decision-making.

Very true Somewhat A little Not at all

e. My work performance is consistently the best I can do.

Very true Somewhat A little Not at all

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