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Click on the appropriate answer:
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Do you
consume at least once per day any of the following: fried foods,
fried chicken, French fries, potato chips, or red meat?
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Yes
No
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Do you
have any of the following: skin tags, ages spots(liver spots),
red spots, or moles increasing in numbers?
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Yes
No
|
Do you
consume at least once per day any of the following: ice cream,
soda pop, candy, dessert, junk food?
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Yes
No
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Do you
weigh 10% more now than what you weighed when you graduated
from high school?
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Yes
No
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Do you
have difficulty falling asleep, staying asleep or sleeping soundly
most nights?
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Yes
No
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Do you
recover slower from cold, flu, wounds, or infection than you
used to?
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Yes
No
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Do you eat
less than five or more servings of fruits and vegetables per
day?
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Yes
No
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Do you participate
in leisure or social activities less than two times per week?
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Yes
No
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Do you worry
about having enough money or have ongoing financial worries?
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Yes
No
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Do you notice
increasing wrinkling on your face, forehead, arms or hands?
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Yes
No
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Do you find
that you are becoming increasingly vulnerable to injuries?
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Yes
No
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Do you experience
feelings of hopelessness or low self esteem frequently?
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Yes
No
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Do you exercise
less than a half hour three times per week?
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Yes
No
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Do you consume
more than one alcoholic beverage per day?
|
Yes
No
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Do you use
caffeine daily in order to stay alert or energetic?
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Yes
No
|
Do you
feel your job or role in society is unrewarding?
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Yes
No
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Do you
have less than two bowel movements per day?
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Yes
No
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Do you
have more than 10% graying of your hair?
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Yes
No
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Do you
suffer from gradual hearing or visual loss?
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Yes
No
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Do you
have sexual activity less than twice weekly?
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Yes
No
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Do you
currently use any tobacco product?
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Yes
No
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Do you
tend to be affected by stress daily?
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Yes
No
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Do you
have a cholesterol level over 200?
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Yes
No
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Do you have
thinning or dull looking hair?
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Yes
No
|
Do you
live with a smoker?
|
Yes
No
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