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- How much sleep do you get on an average night?
a. Less than six hours.
b. Six to eight hours.
c. Nine or more hours.
- Do you suffer from insomnia?
a. Often (most nights).
b. Occasionally (four to eight times a month).
c. Never.
- How often do you exercise vigorously (walking fast, running, swimming, etc.) for 30 or more minutes?
a. Five or more times a week.
b. Two to four times a week.
c. Less than twice a week.
- How often do you perform weight-bearing exercises (walking, hiking, running, weight-training, etc?)
a. Three or more times a week.
b. Twice a week.
c. Less than twice a week.
- How many servings of fruit and vegetables do you eat every day?
a. Between five and nine.
b. Between two and four.
c. I rarely eat fruit or vegetables.
- Roughly what percentage of your diet consists of fats?
a. Between 20 and 30 percent.
b. Over 30 percent.
- Do you make the effort to include omega-3 oils in your diet? (These include flax seed oil, canola oil, walnut oil, and oils from cold-water fish such as salmon, sardines and mackerel.
a. Yes I do, every day.
b. I do, a few times monthly.
c. No, I usually don't consume these oils.
- How often do you eat fresh and/or unsalted nuts?
a. I don't eat nuts.
b. A couple of times a month.
c. A few times a week.
- How often do you eat red meat?
a. No more than once a week (or never).
b. Two or three times a week.
c. Four or more times a week.
- How many servings of low-fat dairy products, such as milk, cheese, yogurt do you consume daily?
a. Three or more.
b. One or two.
c. I don't eat dairy.
- If you answered 'c' to above, do you take a daily calcium supplement?
a. Yes.
b. No.
- In a typical week, how often do you eat breakfast?
a. Always.
b. Three or four times.
c. Once or twice.
d. I don't eat breakfast.
- Since your twenties, have you put on weight?
a. Yes, over ten pounds.
b. Yes, but five pounds or less.
c. No, I weigh the same (or less).
- Does your weight fall within the 'correct' range for your height and age? (Your doctor will be able to provide you with a weight table/chart, or you can look this information up on the Internet or at the library.)
a. Yes, my weight falls within the ideal range.
b. No, I am within ten pounds over my ideal weight.
c. No, I am well over ten pounds above my ideal weight.
- Do you smoke?
a. No. I also spend very little time around people who smoke.
b. No, but I'm exposed to a lot of second-hand smoke.
c. Yes, half a pack per day or less.
d. Yes, one to two packs a day.
e. Yes, more than two packs a day.
- How do you handle the stress in your life?
a. I find stress a positive influence.
b. Stress eats away at me and I often feel out of control.
c. When I feel stressed, I find a way to manage it (for example, through exercise or meditation).
- How much do you drink? (One drink equals 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof spirits.)
a. I seldom drink or never drink.
b. I have two or fewer drinks a day.
c. I have more than two drinks daily.
- Do you have a medical checkup (including, for women, a gyneacological exam) once a year?
a. Yes, I do.
b. No, I don't.
- If you have been diagnosed with a health condition, do you seek and follow the advice of your doctor, pharmacist, and other members of your health care team?
a. Yes, always, and I make sure I am as informed as I can be.
b. Yes, most of the time.
c. I try to but I often forget or can't be bothered.
- Do you keep up-to-date with health news (through newspapers, magazines such as Focus on bettercare, the Internet, TV/radio)?
a. Yes, I make it my business to keep myself informed and to apply that knowledge.
b. No, I don't.
- Do you have more than one relative who lived to 90 years or older in good health?
a. Yes.
b. No.
- Do you have a parent, brother or sister under 50 who has (or had) cancer or a heart condition, or has had diabetes since childhood?
a. Yes, and I do nothing about this.
b. Yes. I have discussed this with my physician and have implemented an action plan to help prevent this condition.
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