Survey 358 en qid code answer sortorder assessment_value language scale_id id sid scope gid name minimum maximum message language Please return this tablet to staff. ]]> cid qid cqid cfieldname method value scenario gid sid group_name group_order description language randomization_group grelevance qid parent_qid sid gid type title question preg help other mandatory question_order language scale_id same_default relevance modulename <![CDATA[Gender]]> <![CDATA[Race]]> <![CDATA[Hispanic]]> <![CDATA[MaritalStatus]]> <![CDATA[Income]]> <![CDATA[Education]]> <![CDATA[Employment]]> <![CDATA[Occupation]]> What is your occupation?

(If retired, list the occupation that you worked most of your life. Then, skip to #27)

]]> <![CDATA[Workday]]> <![CDATA[WorkPhysical]]> <![CDATA[LeisurePhysical]]> <![CDATA[Leisure]]> <![CDATA[Smoking]]> Do you currently smoke or use tobacco products or have you quit in the past 6 months?

If never, skip to #32

]]> <![CDATA[CigarettesDay]]> <![CDATA[SmokingQuit]]> <![CDATA[Alcohol]]> Do you consume alcoholic beverages?

If no, skip to #34

]]> <![CDATA[WeeklyConsumption]]> <![CDATA[Exercise]]> Do you currently exercise?

If no, skip to #38

]]> <![CDATA[ExerciseDaysWeek]]> <![CDATA[ExerciseTimeDay]]> <![CDATA[Activities]]> <![CDATA[MoveAway]]> <![CDATA[PastChanges]]> <![CDATA[TimesLosingWeight]]> <![CDATA[WeightLoss]]> <![CDATA[GainedLost]]> Have you gained or lost any weight in the last 3 months?

If so, please list the amount of weight gained/lost below in lbs. If neither, leave the comment field blank.

]]> <![CDATA[HighestWeight]]> <![CDATA[HighestWeightDate]]> When did you reach your highest weight?

Please estimate.

]]> <![CDATA[Travel]]> <![CDATA[StaffMember]]> <![CDATA[PHQ9]]> Over the last 2 weeks, how often have you been bothered by any of the following problems?]]> <![CDATA[PatientID]]> <![CDATA[Name]]> <![CDATA[PreferredName]]> <![CDATA[Address]]> <![CDATA[Phone]]> What is your phone number?

]]> <![CDATA[Email]]> <![CDATA[PCP]]> <![CDATA[DrList]]> Please list your current doctor(s), specialty, practice name, location, and phone number.

Please choose form the following specialties: PCP (primary care physician), endocrinologist, cardiologist, dermatologist, gynecologist, psychiatrist, opthalmologist, oncologist, rheumatologist, podiatrist, urologist, gastroenterologist, or other.

]]> <![CDATA[ECName1]]> <![CDATA[ECAddress1]]> <![CDATA[ECNumber1]]> <![CDATA[ECRelationship1]]> <![CDATA[ECName2]]> <![CDATA[ECAddress2]]> <![CDATA[ECNumber2]]> <![CDATA[ECRelationship2]]> <![CDATA[SuicideEndorsement]]> Please see staff.

(PHQ9)

]]> qid parent_qid sid gid type title question preg help other mandatory question_order language scale_id same_default relevance modulename <![CDATA[SQ001]]> <![CDATA[SQ002]]> <![CDATA[SQ001]]> <![CDATA[SQ002]]> <![CDATA[SQ003]]> <![CDATA[SQ004]]> <![CDATA[SQ005]]> <![CDATA[SQ001]]> <![CDATA[SQ002]]> <![CDATA[SQ001]]> <![CDATA[SQ002]]> <![CDATA[SQ003]]> <![CDATA[SQ004]]> <![CDATA[SQ001]]> <![CDATA[SQ002]]> <![CDATA[SQ003]]> <![CDATA[SQ004]]> <![CDATA[SQ005]]> <![CDATA[SQ006]]> <![CDATA[SQ007]]> <![CDATA[SQ001]]> <![CDATA[SQ002]]> <![CDATA[SQ003]]> <![CDATA[SQ004]]> <![CDATA[SQ005]]> <![CDATA[SQ006]]> <![CDATA[SQ001]]> <![CDATA[SQ002]]> <![CDATA[SQ003]]> <![CDATA[SQ004]]> <![CDATA[SQ005]]> <![CDATA[SQ001]]> <![CDATA[SQ002]]> <![CDATA[SQ003]]> <![CDATA[SQ004]]> <![CDATA[SQ005]]> <![CDATA[SQ001]]> <![CDATA[SQ002]]> <![CDATA[SQ003]]> <![CDATA[SQ004]]> <![CDATA[SQ005]]> <![CDATA[SQ001]]> <![CDATA[SQ002]]> <![CDATA[SQ003]]> <![CDATA[SQ004]]> <![CDATA[SQ005]]> <![CDATA[SQ001]]> <![CDATA[SQ002]]> <![CDATA[SQ003]]> <![CDATA[SQ004]]> <![CDATA[SQ005]]> <![CDATA[SQ001]]> <![CDATA[SQ002]]> <![CDATA[SQ003]]> <![CDATA[SQ001]]> <![CDATA[SQ002]]> <![CDATA[SQ001]]> <![CDATA[SQ002]]> <![CDATA[SQ003]]> <![CDATA[SQ001]]> <![CDATA[SQ002]]> <![CDATA[SQ003]]> <![CDATA[SQ001]]> <![CDATA[SQ002]]> <![CDATA[SQ001]]> <![CDATA[SQ002]]> <![CDATA[SQ003]]> <![CDATA[SQ001]]> <![CDATA[SQ002]]> <![CDATA[SQ003]]> <![CDATA[SQ001]]> <![CDATA[SQ001]]> <![CDATA[SQ002]]> <![CDATA[SQ003]]> <![CDATA[SQ001]]> <![CDATA[SQ002]]> <![CDATA[SQ003]]> <![CDATA[1]]> <![CDATA[2]]> <![CDATA[3]]> <![CDATA[4]]> <![CDATA[5]]> <![CDATA[6]]> <![CDATA[7]]> <![CDATA[8]]> <![CDATA[9]]> <![CDATA[SQ001]]> <![CDATA[SQ003]]> <![CDATA[SQ001]]> <![CDATA[SQ001]]> <![CDATA[SQ002]]> <![CDATA[SQ003]]> <![CDATA[SQ004]]> <![CDATA[SQ005]]> <![CDATA[SQ002]]> <![CDATA[SQ003]]> <![CDATA[SQ004]]> <![CDATA[SQ005]]> <![CDATA[SQ001]]> <![CDATA[SQ003]]> <![CDATA[SQ001]]> <![CDATA[SQ003]]> <![CDATA[SQ003]]> <![CDATA[SQ002]]> <![CDATA[SQ003]]> qid attribute value language sid gsid admin expires startdate adminemail anonymized faxto format savetimings template language additional_languages datestamp usecookie allowregister allowsave autonumber_start autoredirect allowprev printanswers ipaddr refurl showsurveypolicynotice publicstatistics publicgraphs listpublic htmlemail sendconfirmation tokenanswerspersistence assessments usecaptcha usetokens bounce_email attributedescriptions emailresponseto emailnotificationto tokenlength showxquestions showgroupinfo shownoanswer showqnumcode bouncetime bounceprocessing bounceaccounttype bounceaccounthost bounceaccountpass bounceaccountencryption bounceaccountuser showwelcome showprogress questionindex navigationdelay nokeyboard alloweditaftercompletion googleanalyticsstyle googleanalyticsapikey surveyls_survey_id surveyls_language surveyls_title surveyls_description surveyls_welcometext surveyls_endtext surveyls_policy_notice surveyls_policy_error surveyls_policy_notice_label surveyls_url surveyls_urldescription surveyls_email_invite_subj surveyls_email_invite surveyls_email_remind_subj surveyls_email_remind surveyls_email_register_subj surveyls_email_register surveyls_email_confirm_subj surveyls_email_confirm surveyls_dateformat surveyls_attributecaptions email_admin_notification_subj email_admin_notification email_admin_responses_subj email_admin_responses surveyls_numberformat attachments
you have been invited to participate in a survey.

The survey is titled:
"{SURVEYNAME}"

"{SURVEYDESCRIPTION}"

To participate, please click on the link below.

Sincerely,

{ADMINNAME} ({ADMINEMAIL})

----------------------------------------------
Click here to do the survey:
{SURVEYURL}

If you do not want to participate in this survey and don't want to receive any more invitations please click the following link:
{OPTOUTURL}

If you are blacklisted but want to participate in this survey and want to receive invitations please click the following link:
{OPTINURL}]]>
Recently we invited you to participate in a survey.

We note that you have not yet completed the survey, and wish to remind you that the survey is still available should you wish to take part.

The survey is titled:
"{SURVEYNAME}"

"{SURVEYDESCRIPTION}"

To participate, please click on the link below.

Sincerely,

{ADMINNAME} ({ADMINEMAIL})

----------------------------------------------
Click here to do the survey:
{SURVEYURL}

If you do not want to participate in this survey and don't want to receive any more invitations please click the following link:
{OPTOUTURL}]]>
You, or someone using your email address, have registered to participate in an online survey titled {SURVEYNAME}.

To complete this survey, click on the following URL:

{SURVEYURL}

If you have any questions about this survey, or if you did not register to participate and believe this email is in error, please contact {ADMINNAME} at {ADMINEMAIL}.]]>
this email is to confirm that you have completed the survey titled {SURVEYNAME} and your response has been saved. Thank you for participating.

If you have any further questions about this email, please contact {ADMINNAME} on {ADMINEMAIL}.

Sincerely,

{ADMINNAME}]]>
A new response was submitted for your survey '{SURVEYNAME}'.

Click the following link to see the individual response:
{VIEWRESPONSEURL}

Click the following link to edit the individual response:
{EDITRESPONSEURL}

View statistics by clicking here:
{STATISTICSURL}]]>
A new response was submitted for your survey '{SURVEYNAME}'.

Click the following link to see the individual response:
{VIEWRESPONSEURL}

Click the following link to edit the individual response:
{EDITRESPONSEURL}

View statistics by clicking here:
{STATISTICSURL}


The following answers were given by the participant:
{ANSWERTABLE}]]> 698952 fruity inherit 698952 fruity on on ./files/logo.png on off off fadeInRight 500 off flipInX 500 off shake 500 noto #ffffff #444444 #ffffff on on f00c on rubberBand 500 on zoomIn 500 off off off off off 1