Question Title 1. Please fill in the following Name Address City/Town State/Province ZIP/Postal Code Email Address Phone Number Question Title 2. With which gender do you identify? Male Female Non-binary Other (please specify) Question Title 3. What are your preferred gender pronouns? He/Him She/He They/Them Other (please specify) Question Title 4. With which ethnicity do you most identify? White Black or African American Hispanic or Latino Asian or Asian American Other (please specify) Question Title 5. To which age group do you belong? Under 21 21-38 39-56 57-74 75+ Question Title 6. What is your exact age? Question Title 7. Are you currently under a physician’s care for the treatment of any of the following? Type 2 Diabetes Type 2 Diabetes with Fatty Liver Disease Obesity Gastro-esophageal reflux Heart Failure Hypertension (high blood pressure) Dyslipidemia (unhealthy levels of one or more kinds of fat in the blood) Obstructive sleep apnea Polycystic ovarian syndrome (female subjects only) Chronic kidney disease Gallstones Osteoporosis Pain, anxiety and/or depression Legally Blind Legally Deaf Other (please specify) None of the above Next
