Your Email:

1. How much alcohol do you drink?
2–3 drinks/week
2–3 drinks/month
About 1/day
2+ drinks/day
None

2. When you get frazzled, you?
Lace up your sneakers or call a girlfriend
Take a few deep breaths and keep going
Reach for brownies or other comfort foods
Do nothing

3. How often do you eat red meat?
Every day
One to three times a week
Once or twice a month
I do not eat red meat anymore for at least a year
I have not eaten red meat for over 10 years

4. Your highest level of education is?
High school
Some college
College
Grad school

5. If you were in a personal crisis, how many people would you help out, even if just to drop off a casserole?
Maybe 10
Tons - I have a huge support network
A small group of friends and family
I'd probably go it alone

6. How involved are you in your community at large?
I'm at a school, church, arts or charity activity weekly
I volunteer regularly
I pitch in once or twice a year
I write a check now and then

7. How many times a week do you get 30 minutes of moderate to vigorous exercise?
Every day
Four or five times a week
One to three times a week
Does channel surfing count? (hardly ever exercise)

8. What’s your history with smoking or tobacco?
I’ve never been a smoker or used any tobacco products
I might sneak an occasional smoke on weekends
I’ve quit and I feel much better
I’ve quit but I still have problems with my lungs (past damage)
I’m a regular smoker or use tobacco regularly

9. Which meal best reflects your regular diet?
A burger, fries, and dessert (typical fast-food meal)
Roasted vegetables with quinoa and chickpeas (a plant-based vegan meal)
Salmon with spinach and brown rice (lean protein with veggies)
Penne pasta with chicken and a side salad (mixed diet, moderate choice)

10. Do you drink coffee (or other caffeinated beverages)?
I need at least two or three cups daily
I practically live at Starbucks (multiple caffeinated drinks daily)
I have a cup or less every day
I’m not a fan of coffee / I don’t drink caffeine

11. How many sweetened beverages (soda, sweet tea, lemonade, etc.) do you consume each day?
I guzzle sweetened drinks all day long
I have at least a 16 oz glass or a can of pop with every meal
I limit myself to 2 or 3 sweet beverages per day
I drink on average one sweetened beverage per day
I drink less than one sweet drink per day
I almost never drink sugary drinks

12. How is your sleep habit?
I get 6 to 7 hours of sleep each night
I like to get 8 to 10 hours if I can
I usually squeeze in only about 4 to 6 hours per night
I only get a couple of hours (very little sleep)

13. Let’s talk about your sex life – how often are you sexually active?
I’m not sexually active
I have sex about three times a week on average
More like once a week for me
Maybe once a month or so

14. Which of the following health conditions are present in your first-degree relatives (parents or siblings)?
Heart attack/heart disease, high blood pressure, or high cholesterol in family
Diabetes in family
Cancer or autoimmune diseases in family
A and B only (family history of heart-related issues and diabetes, but not cancer/autoimmune)
All of the above (family has some history of heart disease, diabetes and cancer/autoimmune conditions)
None of the above (no significant first-degree family history of those conditions)

15. How much water do you drink daily? (1 glass = 8 ounces)
At least 8 glasses (64 oz) or more per day
About 5 to 7 glasses per day
About 2 to 4 glasses per day
One glass or less per day

16. What is your religious/spiritual affiliation?
Catholic
Jewish
Protestant Christian (e.g. Baptist, Presbyterian, Methodist, etc.)
Seventh-day Adventist Christian
Muslim
Mormon (Latter-Day Saint)
Buddhist
Hindu
I don’t believe in God (Atheist/Agnostic)
I believe in God but don’t practice or belong to a specific religion
I worship Satan / the powers of darkness
Jehovah’s Witness

17. What is your ethnicity?
White (Non-Hispanic)
Black or African-American
Native American
Hispanic/Latino
Mixed or any other ethnicity

18. What is your Height?

19. How often do you weigh yourself?
Every day or even several times per day
Several times per week
About once per month (or every other month)
Never, or only at the doctor’s office once a year
I don’t go to the doctor and I never weigh myself

20. What is your Current Weight?

21. What is your gender?
Male
Female

22. What is your Date of Birth?