Lifestyle Sample Survey

This is a sample survey asking a series of lifestyle questions. It illustrates a one-page format with section breaks. Normally you might use this space to present an introduction or instructions.


The following table asks you to indicate whether the statement at the left side of a row or the one on the right side better describes you. Please check the button that represents how much better one describes you than the other.




I like to play sports I like to watch sports
I like to watch TV I like to read
I stay up late I go to sleep early
I am a gourmet Food is food
I like beer I like wine

Eating Out

How many times have you eaten out in a restaurant in the past month? 

Which of the following types of restaurants do you like to visit?

American - Traditional      Mexican
American - Contemporary      Chinese
French      Japanese
Italian      Other  


Which of the following leisure activities do you do at least once a month?

Go to a movie      Go to an art museum
Go to a concert      Go to a history museum
Attend a live theatre performance      Visit a theme park
Attend a sports event      Swim

In which of the following sport do you participate at least once a month?

Hiking      Tennis
Swimming      Golf
Sailing      Bike riding
Team sports      Horseback riding


What is your gender?

Male      Female

Into which group does your age fall?

18-24      50-64
25-34      65 or older