BRANDAUVITAL · QUESTIONNAIRE
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👤 Personal Details
Gender
*
Male
Female
Non-binary
First name
*
Middle name
Last name
*
Birth name
Date of birth
*
Place of birth
Time of birth
Type of birth
Natural
C-section (emergency)
C-section (planned)
Vacuum extraction
Other
City of residence
Postal code
House number
Primary care / treating physician
Origin / ethnicity (me)
European / Caucasian
African / African-American
Middle Eastern
South Asian
Northeast Asian / Arctic
Pacific Islander
Indigenous American
Southeast/East Asian
Unknown
Origin / ethnicity (mother)
European / Caucasian
African / African-American
Middle Eastern
South Asian
Northeast Asian / Arctic
Pacific Islander
Indigenous American
Southeast/East Asian
Unknown
Origin / ethnicity (father)
European / Caucasian
African / African-American
Middle Eastern
South Asian
Northeast Asian / Arctic
Pacific Islander
Indigenous American
Southeast/East Asian
Unknown
Occupation
Type of work
Office / sedentary
Office alternating (sitting & standing)
Standing (retail, cashier, reception)
Manual / physical labor
Healthcare
Management position
Self-employed / entrepreneur
Home office
Shift work
Student / in training
Unemployed
Not employed
Other
Marital status
Single
Married
Divorced
In a relationship
Children
None
1 child
2 children
3 children
More than 3
Insurance
Statutory (public)
Private
When are you best reachable?
From 6:00 am
Morning
Midday
Afternoon
Evening
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