In general, how would you rate your overall health?

Question Title

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

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

Question Title

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

What is your current weight in pounds?

Question Title

* 3. What is your current weight in pounds?

Do you currently smoke cigarettes, or not?

Question Title

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

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

Question Title

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

About how many alcoholic drinks do you have each week?

Question Title

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

How many hours do you sleep each night?

Question Title

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

1 12
i We adjusted the number you entered based on the slider’s scale.
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)?

Question Title

* 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)?

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

Question Title

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

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

Question Title

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

About how often do you eat fast food?

Question Title

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

About how often do you eat at a restaurant?

Question Title

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

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

Question Title

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

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

Question Title

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

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

Question Title

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

How often do you wear a seatbelt when in a car?

Question Title

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

When is the last time that you saw a doctor?

Question Title

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

When is the last time that you saw a dentist?

Question Title

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

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

Question Title

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

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?

Question Title

* 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?

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.

Question Title

* 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.

T