Personal Information
Todays Date:(mm/dd/yyyy) Name: Age: Height:(without shoes) Weight: What is the most you have ever weighed?: Sex:MaleFemale
Are you NOW trying to: Lose weight Gain weight Stay about the same Not trying to do anyhting
Medical History
YESNO
Has your father or brother had a heart attack or died suddenly of heart disease before age 55 years; has your mother or sister experienced these heart problems before age 65 years?
Has a doctor told you that you have high blood pressure (more than 140/90 mm Hg), or are you on medication to control your blood pressure?OR If you know your blood pressure please check the appropriate category: Less than 120/80 mm Hg 140/90 to 159/99 Do Not Know 120/80 to 129/84 >160/100 to 180/110 130/85 to 139/89 More than 180/110
OR
If you know your blood pressure please check the appropriate category: Less than 120/80 mm Hg 140/90 to 159/99 Do Not Know 120/80 to 129/84 >160/100 to 180/110 130/85 to 139/89 More than 180/110
Is your total blood cholesterol greater than 240 mg/dl, or has a doctor told you that your cholesteral is at a high risk level? OR If you know your blood cholesterol, please check the appropriate category: Less than 160 mg/dl 200-219 More than 260 160-179 200-219 Do not know 180-199 220-260
If you know your blood cholesterol, please check the appropriate category: Less than 160 mg/dl 200-219 More than 260 160-179 200-219 Do not know 180-199 220-260
Do you have diabetes?
During the past year, would you say that you experienced enough stress, strain, and pressure to have a significant effect on your health
Health and Nutrition
In general, compared to other persons your age, rate how healthy you are: 1 2 3 4 5 6 7 8 9 10 1 Being Not healthy at all; 10 being Extremely healthy
Outside of you normal work or daily responsibilities, how often do you engage in exercise that at least moderatly increases your breathing and heart rate, and makes you sweat, for atleast 20 minutes (such as brisk walking, cycling, swimming, jogging, aerobic dance, stair climbing, rowing, basketball, racquetball, vigorous yard work, etc.)
5 or more times per week 3 to 4 times per week 1 to 2 times per week Less than 1 time per week Seldom or never
Do you eat foods nearly every day that are high in fat and cholesterol such as fatty meats, cheese, fried foods, butter, whole milk, ice cream, or eggs?
On average, how many servings of fruit and vegetables do you eat per day? (One serving=1 medium fruit, 1/2 cup of chopped, cooked, or canned fruit/vegetables, 3.4 cup of fruit or vegetable juice). None 1-2 3-4 5-6 7-8 9 or more
On average, how many servings of bread, cereal, rice, or pasta do you eat per day? ( One serving=1 slice of bread, 1 ounce of ready-to-eat cereal, 1/2 cup of cooked cereal, rice, or pasta). None 1-2 3-5 6-8 9-11 12 or more
Lifestyle Habits
How have you been feeling in general during the past month?
In excellent spirits In good spirits mostly In low spirits mostly In very good spirits I've been up & down in spirits a lot In very low spirits
On average, how many hours of sleep do you get in a 24 hr period? Less than 5 5 to 6.9 7 to 9 More than 9
How would you discribe your smoking habits? Never smoked Used to smoke
How many years has it been since you smoked? Less than 1 year 6-15 1-5 More than 15
Still smoke
How many cigarettes a day do you smoke on average? 1-10 21-30 More than 40 11-20 31-40
How many alcoholic drinks do you consume? (A "drink" is a glass of wine, a wine cooler, a bottle/can of beer, a shot glass of liquor, or a mixed drink).
Never use alcohol Less than 1 per week 1 to 6 per week 1 per day 2 to 3 per day More than 3 per day
When driving or riding in a car, do you wear a seat belt: All or most of the time Some of the time Once in a while Rarely or never
