Overall, how would you rate your health today?
In the last 7 days, which symptoms did you experience? (Select all that apply)
- Pain
- Fatigue or tiredness
- Shortness of breath
- Nausea
- Dizziness
- Sleep problems
- Anxiety or stress
- Fever or chills
- None of the above
- Other
If you selected Other, please specify (optional).
Max 100 chars
In the last 7 days, how severe were the following? Select “None” if not experienced.
In the last 7 days, how much did pain interfere with your daily activities?
In the last 7 days, how often did you feel unusually tired?
Are you currently receiving treatment related to your condition?
- Yes, currently receiving treatment
- No, completed treatment in the last 3 months
- No, no treatment in the last 3 months
In the last 7 days, which treatment side effects did you notice, if any? (Select all that apply)
- Nausea or upset stomach
- Headache
- Drowsiness
- Dry mouth
- Dizziness
- Skin rash or irritation
- Injection site pain
- Mood changes
- None of the above
- Other
If you selected Other side effects, please specify (optional).
Max 100 chars
Overall, how burdensome were treatment side effects in the last 7 days? (If none, select Not burdensome.)
During the last 7 days, on how many days were you limited in your usual activities?
Overall sleep quality in the last 7 days:
In the last 7 days, how often did you experience the following?
Compared with one month ago, how is your overall quality of life?
- Much worse
- A little worse
- About the same
- A little better
- Much better
Attention check: To confirm attention, please select “Sometimes.”
- Never
- Rarely
- Sometimes
- Often
- Always
What is your age group?
- 18–24
- 25–34
- 35–44
- 45–54
- 55–64
- 65–74
- 75+
- Prefer not to say
Which of the following best describes your gender?
- Woman
- Man
- Non-binary
- Prefer to self-describe
- Prefer not to say
If you prefer to self-describe your gender, please enter it here (optional).
Max 100 chars
Where do you currently live?
What is the highest level of education you have completed?
- Less than high school
- High school or equivalent
- Some college or technical training
- Bachelor’s degree
- Graduate or professional degree
- Prefer not to say
What is your current employment status?
- Employed full-time
- Employed part-time
- Self-employed
- Unemployed
- Student
- Homemaker or caregiver
- Retired
- Unable to work
- Prefer not to say
Is there anything else you would like to share about your health, treatment, or daily life?
Max 600 chars
AI Interview: 2 Follow-up Questions on your recent health and daily life
Thank you for completing this survey. Your feedback is appreciated.