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This questionnaire is designed to increase your knowledge and awareness of your overall health. It doesn't compare you to the rest of the world. It will show you areas that you are making healthy choices and where there is room for improvement. Keep in mind that you can modify of health risk factors such as blood pressure, smoking, blood cholesterol levels, exercise, diet, stress, and excess body weight.

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Your full name:

Your email address: (e.g.: you@aol.com)

Do you exercise or play a sport for at least thirty minutes three or more times a week?
Yes
No

Do you warm up and cool down by stretching before and after exercising?
Yes
No

Are you within the appropriate weight category for someone your height and gender?
Yes
No

In general, are you pleased with the condition of your body?
Yes
No

Are you satisfied with your current level of energy?
Yes
No

Do you use the stairs rather than escalators or elevators whenever possible?
Yes
No

Do you have close relative who had a heart attack before age forty?
No
Yes

Do you have high blood pressure requiring treatment?
No
Yes

Have you developed diabetes?
No
Yes

Have you developed gout?
No
Yes

Have you developed cancer?
No
Yes

Do you have a dental checkup at least once a year?
Yes
No

Do you examine yourself for unusual changes or lumps monthly?
Yes
No

Do you use sunscreen regularly and avoid extensive exposure to the sun?
yes
No

Do you normally get an adequate amount of sleep?
Yes
No

Do you drink enough water so that your urine is a plae yellow color?
Yes
No

Do you try fad diets?
No
Yes

Do you minimize your intake of sweets, especially candy and soft drinks, and avoid adding sugar to foods?
Yes
No

Do you eat high-fiber foods (vegetables, fruits, whole grains) several times a day?
Yes
No

Is your diet well-balanced (includes all food groups)?
Yes
No

Do you limit your intake of saturated fats (butter, cheese, cream, fatty meats)?
Yes
No

Do you limit your intake of cholesterol (eggs, liver, meats)?
Yes
No

Do you use tobacco products (smoke or chew)?
No
Yes

Do you limit yourself to no more than two alcoholic drinks a day?
Yes
No

Do you use alcohol or other drugs as a way of handling stressful situations or problems in your life?
No
Yes

Do you follow the label directions when using prescribed and over-the-counter drugs?
Yes
No

Do you want to improve your health?
Yes
No

Do you include relaxation time as part of your daily routine?
Yes
No

Have your health, eating, or sleeping habits changed as a result of a stressful incident or situation?
No
Yes

Are you satisfied with the support you provide to others?
Yes
No

Are you satisfied with your level of sexual activity?
Yes
No

Do you wake up feeling rested?
Yes
No

Do you miss many days at work (daily activities) due to illness or just not feeling up to it?
No
Yes

Are you satisfied with your leisure time?
Yes
No