Sleep

How many hours do you usually sleep per night?

• 5 hours or less
• 6 hours
• 7-8 hours
• 9 hours or more

 Exercise

How often do you get vigorous physical activity for at least 20-30 minutes?
(Examples: Brisk walking, gardening, jogging, sports, swimming, or cycling.)

• Daily
• Most every day
• Less than 3 times a week
• Rarely

 Alcohol Use

How many servings of alcohol do you drink in a week?

• None
• 1-2 Servings
• 3-10 Servings
• Over 10 Servings

 Smoking History

I have never smoked
I have quit smoking
I smoke less than 1 pack a day
I smoke more than 1 pack a day

 Diet

How often do you eat only plant-based foods? (No meat or dairy products.)

• Almost Every Day
• Sometimes
• Rarely or never

 Nutrition

How often do you eat foods containing refined sugar or oil?

• Almost every day
• Once in a while
• Rarely or never

 Emotional Well-being

How was your sense of emotional well-being this past week?

• Happy
• Up and down
• Sad
• Depressed