Join South Asian Food Survey
Please answer all the questions to join this research study. Your answers are kept confidential and will not be shared with anyone except the research team.
1. Name
*
First Name
Last Name
2. Email
*
example@example.com
3. Phone Number
*
-
Area Code
Phone Number
4. What is your year of birth?
*
4b. What is your sex?
*
Male
Female
Prefer not to answer
5. Are you of South Asian descent?
*
Yes
No
6. Are you pregnant or breastfeeding?
*
Yes
No
7a. Enter Weight in kg.
*
in whole kilograms
7b. Enter Height in cm.
*
in whole centimeters
8. Has your diet changed significantly in the past year?
*
Yes
No
8b: Please specify the diet change
9. Has your weight changed significantly in the past year?
*
Yes
No
9b. How much has your weight changed?
*
in whole kilograms
10. Have you been diagnosed with or experienced any of the conditions listed below?
*
Heart disease
Stroke
High Cholesterol
High blood pressure
Kidney disease
Cancer
Diabetes (Type 1 or 2)
Bowel or gastrointestinal surgery
Food intolerances or conditions which cause gastrointestinal symptoms (i.e. celiac disease, gluten sensitivity, lactose intolerance)
Long term diarrhea or constipation
Autoimmune disease (e.g. Celiac disease, Rheumatoid arthritis, Multiple Sclerosis)
Liver disease
Chronic abdominal pain
None of the above
11. If any, how many standard drinks of alcohol do you consume per week? (1 standard drink is 1 beer (330ml), 100ml wine or 30ml of spirits)
*
Enter amount of standard drinks.
12. Do you follow a lactose-free or gluten-free diet?
*
Yes
No
13. Do you have an inflammatory bowel disease diagnosis?
*
Yes
No
13b. Which IBD have you been diagnosed with?
*
Crohn's disease
Ulcerative colitis
Other
Result
*
Pass
Fail
source
area
weight change
bmi
Wayturn contact email
Continue
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