Smoking
None
Smoke less than a year
Smoke 1-5 years
Smoke 5-10 years
Smoke 10+ years
How many Cigarettes do you smoke daily?
None
One a day or less
Half a pack a day
Full pack
More than a pack
Drink Alcohol
Do you drink more than two drinks a day
No
Yes
Do you get intoxicated on a weekly basis
No
Yes
Drugs
Do you do any drugs consistently
No
Yes
Athletic Activity
None
Exercise vigorously 3 times a week for 30 minutes plus
Moderate exertion 2-3 times a week
Once a month
Rarely
Height and Weight
None
Anyone with BMI over 25
Anyone with BMI over 30
Anyone with BMI over 40
Anyone with BMI that is normal
Weight fluctuated more than 10 pounds several times since high school
How Many Grandparents age past 80
Blood pressure
None
129/84 or less
130-139/85/89
140-159/90-99
160 & over, 100 & over
Cholesterol level
None
Total cholesterol level under 240
Total cholesterol level over 240
DIET
None
Organic, farm grown Low fat food with five or more fruits and veggies per day
Low fat food with five or more fruits and veggies per day
High fat foods balanced with fruit and veggies
High fat foods with very little fruit and veggies
DRIVING
Driving violatons past 3 years
None
1 or less
Two - Four
More than four
Wear Seatbelt
None
Always
Usually
Sometimes
Never
Your overall demeanor is:
None
Easy going
Intense or Easily irritated
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