Community Health and Spending Survey

Bring together family conditions, current symptoms, medication, allergies and monthly spending on medicines for population studies. Researchers, NGOs and public health programmes use it to quantify the health burden of a community. Tobacco, substance and alcohol use are covered as well.

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Full name*

Nombre

Apellido

Gender*

Female Male Non-binary Prefer not to say

Current age*

Email*

Phone number*

Address*

Dirección

Ciudad

Estado / Provincia

Código postal

Tick the conditions that affect you or a close relative*

Diabetes High blood pressure Heart disease Asthma Cancer Thyroid disorder None of these

Tick the symptoms you have right now*

Fatigue Headache Fever Cough Joint pain Digestive discomfort None of these

Are you taking any medication at present?*

Yes No

Are you allergic to any medication?*

Yes No Not sure

Medicines prescribed by your doctor*

Monthly spending on medicines*

Do you use or have you used tobacco?*

Do you use or have you used illegal drugs?*

How often do you drink alcohol?*

I do not drink Occasionally A few times a month Weekly Daily

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