Gender:

Male
Female

Age:

under 50
50-65
65+

Retired:

yes
no

Self Employed:

yes
no

Company Employed:

yes
no

Household Income:

Under $50,000
$50,000-$100,000
$100,000+

Home Ownership:

Rent
own

Mortgage:

Yes
No

Second Home/Vacation Home:

Yes
No

Marital Status:

Single
Married
Divorced/Single

College Degree:

Yes
No

Occupation?

Traveled within the last 12 months?

yes
no

If so: (check all that apply)

Big Island
Kauai
Lanai
Maui
Molokai
Mainland
Other

Number of Trips?

Average number of times per month Dining Out:

1-5
5-10
10+

Average number of times per month you visit the Shopping Mall:

1-5
5-10
10+

How much do you spend on average per visit:

under $50
$50-$100
$100+

What do you buy: (check all that apply)

Clothing & Accessories
Household goods
Jewelry
Furniture/Bed/Bedding
Gifts
Other

What story/stories did you find most interesting/beneficial in this or previous issues?

Have you bought a new vehicle in the last 12 months:

yes
no

Do you plan to purchase a new vehicle in the next 12 months:

yes
no

Which Generations Hawaii Cover was your favorite?

How many books do you read per month?

Reasons for going on-line (check all that apply):

Emailing
Shopping
News/Info
Gaming
Work
Travel Arrangements
Other

How many hours per week do you spend on physical activity?

Do you have children at home:

yes
no

Do you have adult children who have returned to live at home:

yes
no

Are you a grandparent:

yes
no

How many hours per week do you spend on-line?

If so, average age of grandchildren?

How many doctor prescribed medications are you currently taking?

(Optional)
If you would like to participate in the drawing for the dining certificate, please provide the following:

Name:

Address:

City:

State:

zip:

Phone:

Email: