General
Age
Gender
Male
Female
How
would you rate your physical health compared
to others your chronological age?
Excellent
Very good to fair
Poor
Extremely poor
Health
Measurements
Does
your weight fluctuate?
Weight changes of no more
than 5%
in any 5
year period since age 25
Weight changes from 5% to
10% in
any
5 year period since age 25
Weight changes of more than
10%
in any
5 year period since age 25
What
is your Blood Pressure?
Lower than 90/65
Between 90/65 to 120/81
121/82 to 130/86
131/87 to 140/90
141/91 to 150/95
Higher than 151/96
Don't know
What
is your Heart Rate?
Lower than 76 beats per minute;
less than
30 minutes of stamina
exercise per
week
Lower than 76 beats per minute;
more than
30 minutes of
stamina exercise
per week
76 to 91 beats per minute;
less
than 30 minutes
of stamina
exercise per week
76 to 83 beats per minute;
more
than 30 minutes
of stamina exercise
per week
83 to 91 beats per minute;
more than
30 minutes of stamina
exercise per week;
OR higher than 91
beats per minute; less
than 30 minutes
of stamina exercise per
week
Higher than 91 beats per
minute;
more than
30 minutes of stamina
exercise per
week
Don't know
What
is your Total Cholesterol?
Less than 160 mg/dL
161 to 200 mg/dL
201 to 240 mg/dL
241 to 280 mg/dL
More than 280 mg/dL
Don't know
HDL
(Good Cholesterol)
55 or more
45 to 54
40 to 44
Less than 40
Don't know
Disease
Have
you ever had a Heart Attack?
No
I have had a heart attack
involving
inferior
or posterior part of heart
I have had a heart attack
involving
anterior
part of heart
Have
you ever had a Stroke?
No
Ischemic stroke (inadequate
blood
flow to brain)
Hemorrhagic stroke (bleeding
into
the brain)
Do
you have Diabetes?
No
Type II (adult onset)
Type I (juvenile onset)
Have
you ever suffered from Depression?
I never feel depressed
I rarely feel depressed
I have had severe depression
and/or have
attempted suicide
None of the choices apply
Habits
What's
your cigarette smoking status?
1
pack-year equals 1 pack a day for 1 year.
2
pack-years equal 2 packs a day for 1 year,
or 1 pack a day for 2 years.
Non-smoker
Ex-smoker, for more than
5 years
Ex-smoker, for 3 to 5 years
Ex-smoker, more than 1 year
but
less than
3 years
Ex-smoker, for 5 months to
1 year
Smoker, 0 to 20 pack-years
Smoker, more than 20 pack-years
How
many cigars do you smoke per week?
Non-smoker
Less than 1 cigar per week
1 to 3 cigars per week
4 or more cigars per week
How
many hours per day are you exposed to secondhand
smoke?
Never
Some, but less than 1 hour
per day
1 to 3 hours per day
More than 3 hours per day
Exercise
Over
the past 3 years, on average, how many minutes
per week do you spend exercising?
More than 90 minutes per
week
60 to 90 minutes per week
20 to 59 minutes per week
10 to 19 minutes per week
5 to 9 minutes per week
Less than 5 minutes per week
Over
the past 3 years, on average, how many minutes
per week do you do strength-building exercises?
30 minutes or more per week
Less than 30 minutes per
week
None
Diet
How
many milligrams (mgs) of Calcium do you
get from supplements per day?
More than 1,200 mg per day
800 to 1,200 mg per day
500 to 800 mg per day
Less than 500 mg per day
Don't know
How
many micrograms (mcgs) of Folic Acid do
you get from supplements per day?
More than 400 mcgs per day
Between 224 and 400 mcgs
per day
Less than 224 mcgs per day
Don't know
How
many milligrams (mgs) of Vitamin C do
you get from supplements per day?
Females,
50 years or older
Greater than 1,000 mg
per day
Between 160 to 1,000 mg
per day
Less than 160 mg per day
Don't know
Doesn't apply
Males,
40 years or older
Greater than 1,000 mg per day
Between 160 to 1,000 mg
per day
Less than 160 mg per day
Don't know
Doesn't apply
How
many IU's of Vitamin E do you get from supplements
per day?
Females,
50 years or older
400 or more IU's per day
Less than 400 IU's per
day
Don't know
Doesn't apply
Males,
40 years or older
400 or more IU's per day
Less than 400 IU's per
day
Don't know
Doesn't apply
How
many servings of fish do you have per week?
(A serving is the size of a pack of playing
cards.)
More than 2 servings per
week
Some, but less than 2 servings
of
fish per
week
None
How
many meals with tomato paste (e.g. any meal
with a pizza or marinara sauce) do you have
per week?
Males
Only
More than 10 servings per week
2 to 10 servings per week
Less than 2 servings per
week
None
How
many times per week do you eat breakfast?
More than 5 times per week
3 to 5 times per week
2 or fewer times per week
None
How
many servings of fruits and vegetables do
you have per day?
5 or more servings per day
1 to 5 servings per day
None
How
many alcoholic beverages do you drink per
day?
Females
Only
None
1/2 to 1 alcoholic drink
per day
More than 1 alcoholic drink
per day
Males
Only
None
Less than 1 alcoholic drink per day
1 alcoholic drink per day
2 or more alcoholic drinks per day
Safety
How
fast do you typically drive?
4 miles per hour or less
over the
speed limit
5 to 14 mph over the speed
limit
15 or more miles over the
speed
limit
None of the choices apply
How
often do you use seat belts and are protected
by an airbag?
Seat belts were worn 10 of
10
times, AND
car had air bags 10 of
10 times
Seat belts were worn 7-9
of 10
times, AND
car had air bags 6 of 10
times
Seat belts were worn fewer
than 7
of 10 times,
AND car had air bags
fewer than
6 of 10 times
None of the choices apply
How
often do you use a cellular phone?
I never use a cellular
phone while
I am driving
1 to 2 times on days that
I drive
MORE than 2 times on days
that
I drive
Family
What's
your marital status?
Married man
Married woman
Single woman, widowed woman
Divorced man, widowed man
Divorced woman
Single man
None of the choices apply
Over
the last year, how many major disruptive
events (for example, death in family, relocation,
financial difficulties) have you had?
None
One
Two
Three or more
How
many social groups do you belong to and/or
how many close friends do you have?
Three or more
Two
One
None
Do
you have a sense of humor and can you laugh
at situations?
Yes
No
How
old are your biological parents?
Both lived past 75
One lived past 75
Neither lived past 75
Doesn't apply