* 1. In general, how would you rate your overall health?

* 2. What is your height in feet and inches? For example, if you are 5 feet and 4 inches, write 5’4”.

* 3. What is your current weight in pounds?

* 4. Do you currently smoke cigarettes, or not?

* 5. Does anyone in your household currently smoke cigarettes, or not?

* 6. About how many alcoholic drinks do you have each week?

* 7. How many hours do you sleep each night?

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i We adjusted the number you entered based on the slider’s scale.

* 8. About how many times in the average week do you engage in 30 minutes of light activity (i.e. leisurely walking, gardening, cleaning around the house)?

* 9. About how many times in the average week do you engage in 30 minutes of moderate activity (i.e. brisk walking, light bicycling)?

* 10. About how many times in the average week do you engage in 30 minutes of strenuous activity (i.e. running or jogging)?

* 11. About how often do you eat fast food?

* 12. About how often do you eat at a restaurant?

* 13. About how many cups of fruit do you eat each day? If you don’t know for certain, please provide an estimate.

* 14. About how many cups of vegetables do you eat each day? If you don’t know for certain, please provide an estimate.

* 15. How often do you use sunscreen while out in the sun?

* 16. How often do you wear a seatbelt when in a car?

* 17. When is the last time that you saw a doctor?

* 18. When is the last time that you saw a dentist?

* 19. During the past 4 weeks, how bothered did you feel by emotional problems such as feeling anxious, depressed, irritable, or sad?

* 20. During the past 4 weeks, how disruptive were your physical health or emotional problems to your normal social activities with family, friends, neighbors, or groups?

* 21. During the past 4 weeks, how supported did you feel when you wanted or needed help from others? For example, if you felt lonely and wanted to talk to someone or got sick.

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