1. Gender---- Select From The List ----MaleFemaleTransgender WomanTransgender ManNon-BinaryAgender/I don’t identify with any genderGender not listedPrefer not to state2. Birthday3. Race/Ethnicity African-American Asian Caucasian Hispanic Native American Pacific Islander Other 4. Height4’0"4’1"4’2"4’3"4’4"4’5"4’6"4’7"4’8"4’9"4’10"4’11"5’0"5’1"5’2"5’3"5’4"5’5"5’6"5’7"5’8"5’9"5’10"5’11"6’0"6’1"6’2"6’3"6’4"6’5"6’6"6’7"6’8"6’9"6’10"6’11"7’0"7’1"7’2"7’3"7’4"7’5"7’6"7’7"7’8"7’9"7’10"7’11"5. Weight (pounds)80818283848586878889909192939495969798991001011021031041051061071081091101111121131141151161171181191201211221231241251261271281291301311321331341351361371381391401411421431441451461471481491501511521531541551561571581591601611621631641651661671681691701711721731741751761771781791801811821831841851861871881891901911921931941951961971981992002012022032042052062072082092102112122132142152162172182192202212222232242252262272282292302312322332342352362372382392402412422432442452462472482492502512522532542552562572582592602612622632642652662672682692702712722732742752762772782792802812822832842852862872882892902912922932942952962972982993003013023033043053063073083093103113123133143153163173183193203213223233243253263273283293303313323333343353363373383393403413423433443453463473483493503513523533543553563573583593603613623633643653663673683693703713723733743753763773783793803813823833843853863873883893903913923933943953963973983994004014024034044054064074084094104114124134144154164174184194204214224234244254264274284294304314324334344354364374384394404414424434444454464474484494504514524534544554564574584594604614624634644654664674684694704714724734744754764774784794804814824834844854864874884894904914924934944954964974984995005015025035045055065075085095105115125135145155165175185195205215225235245255265275285295305315325335345355365375385395405415425435445455465475485495505515525535545555565575585595605615625635645655665675685695705715725735745755765775785795805815825835845855865875885895905915925935945955965975985996006. Would you say that your health in general is... Excellent Good Fair Poor 7. In general, how satisfied are you with your life? (e.g., work situation, social activity, accomplishing what you set out to do) Very satisfied Mostly satisfied Somewhat satisfied Not satisfied 8. Have you ever been diagnosed with depression? Yes No 9. What is your current level of stress in your personal life? Low Medium High Very High 10. What is your current level of stress in your work life? Low Medium High Very High 11. Are you receiving treatment (medication and/or counseling) for depression? Yes No 12. How often do you use prescription drugs or over-the-counter medications which affect your mood to help you to relax? Zero One or 2 3 to 4 5 to 7 13. How frequently do you floss your teeth? Daily Most days Sometimes Rarely Never 14. How often do you get enough sleep to function well in your job and personal life? Always Most of the time Sometimes Rarely Never 15. How often do you exercise each week? 0 to 2 days 3 to 4 days 5 days 6 to 7 days 16. At what level of exertion do you exercise usually? Mild Moderate Vigorous Mild physical activity is defined as activity that carries a “perceived exertion” (how hard you think you are working) of very light. It is equivalent to household chores, including activities such as sweeping floors, scrubbing, washing windows, and raking the lawn. Moderate physical activity is defined as activity that causes some increase in breathing and/or heart rate, and carries a “perceived exertion” of somewhat hard. It is the effort a healthy individual might expend while walking briskly, mowing the lawn, dancing, swimming, or bicycle on level ground. Vigorous physical activity is defined as activity that causes a large increase in breathing and/or heart rate, and carries a “perceived exertion” of hard. It is the effort a healthy individual might expend while jogging, mowing the lawn with a non-motorized push mower, participating in high-impact aerobic dancing, swimming continuous laps, or bicycling uphill.17. On days that you exercise, how long do you exercise usually? Less than 30 minutes each day 30 minutes each day Greater than 30, but less than 60 minutes each day 60 minutes or more each day 18. How many cigarettes do you smoke per day? Zero One to 10 More than 10 I smoke cigarettes, but not daily 19. How often do you smoke cigars? Never Daily Weekly Monthly Less than once a month 20. How often do you chew tobacco? Never Daily Weekly Monthly Less than once a month 21. Are you exposed regularly to secondhand tobacco smoke? Yes No 22. How many days per week do you drink alcohol? Zero One or 2 3 to 4 5 to 7 23. On days that you consume alcohol, how many alcoholic drinks* do you consume? Zero One or 2 More than 2, but less than 5 More than 5 *An alcoholic drink is defined as 12oz. of beer, 5 oz. of wine or 1.5 oz. of 80-proof liquor24. Have you received an influenza vaccine (flu shot) within the past year? Yes No 25. Have you ever received a pneumonia vaccine? Yes No 26. Do you have Diabetes? Yes No Unknown If YES, what type? Type 1 Type 2 27. Have you had your blood sugar (blood glucose) checked within the past year? Yes No 28. Have you been diagnosed with any of the following? Yes, Asthma Yes, Back Pain Yes, Cancer Yes, Heartburn or Acid Reflux Yes, Heart Problems Yes, Kidney Disease No 29. Have you had your blood pressure measured by a healthcare provider in the past year? Yes No 30. Are you currently taking any medication for high blood pressure? Yes No 31. Have you had your Cholesterol taken by a healthcare provider in the past year? Yes No 32. Do you know your total Cholesterol? Yes No 33. Are you currently on any medications to treat Cholesterol? Yes No 34. Have your grandparents, parents, brothers, or sisters ever had any of the following diseases? (Check all that apply) Diabetes High Blood Pressure High Cholesterol Cancer Heart Disease Stroke Osteoporosis Unknown 35. When driving or riding in a car, how often do you wear a seat belt? Always Most of the time Less than half the time Seldom or never 36. Are you careful to protect your skin from sunburn by using sunscreen? Yes No 37. Do you usually wear sunglasses when spending time outside in bright sunlight? Yes No 38. How many days did you miss from work due to illness or injury during the past 12 months? Zero 1 to 3 days 4 to 7 days 8 or more days 39. Have you ever had a physical exam? Yes No If YES, when was it last done? Within the past year Within the past two years Within the past three years Within the past four years Five or more years ago 40. For MEN ONLY: Have you ever had a Prostate Exam? Yes No If YES, when was it last done? Within the past year Within the past two years Within the past three years Within the past four years Five or more years ago 41. For WOMEN ONLY: Have you ever had a Mammogram? Yes No If YES, when was it last done? Within the past year Within the past two years Within the past three years Within the past four years Five or more years ago 42. For WOMEN ONLY: Have you ever had a Pap smear? Yes No If YES, when was it last done? Within the past year Within the past two years Within the past three years Within the past four years Five or more years ago 43. How often do you eat fast food? Four or more times per week Two or three times per week Two to four times per month Within the past four years Seldom or never 44. How often do you eat snack foods between meals (chips, soft drinks, candy, cookies)? Three or more times per week Once or twice per day Few times per week Seldom or never 45. Indicate the kind of foods you usually eat? Nearly always eat the high fat foods Eat mostly high fat foods, some low fat Eat both about the same Eat mostly low fat foods, some high fat Eat only low fat foods High Fat examples: hamburgers, hot dogs, bologna, steaks, sour cream, cheese, whole milk, eggs, butter, cake, pastry, ice cream, chocolate, fried foods, fast food Low Fat examples: lean meat, skinless poultry, fish, skim milk, low fat dairy products, fruit desserts, gelatin, vegetables, pasta, peas and beans46. About how many cups of fruit do you eat each day? Four or more Three Two One Less than one (One cup of fruit = one small piece of fruit, one cup of cut-up fruit, one cup of 100% fruit juice, or 1/2 cup of dried fruit)47. How often do you use over the counter drugs, dietary supplements, or herbal products to help you manage your weight, enhance athletic performance, or treat depression? Daily Weekly Monthly Seldom Never Δ
