Name:

Gender:
Male
Female

Age Group:
Under 21
21 to 35
36 to 50
51 to 65
Over 66

Do you smoke or live/work with a smoker, or live in an air polluted area?
Yes No

Do you exercise at least three times a week for 20 or more minutes?
Yes No

Do you drink more than ten alcoholic beverages a week?
Yes No

Do you have high cholesterol levels and/or a family history of heart disease?
Yes No

Do you consume more than two cups of caffeinated coffee or four caffeinated sodas per day?
Yes No

Do you currently take vitamin supplements each day?
Yes No

Are you currently dieting? (consuming fewer than 2,000 calories per day)
Yes No

Would you like to reduce your weight?
Yes No

Do you believe that you eat a balanced diet?
Yes No

Do you or anyone in your immediate family have a history of heart disease (heart attack, angina, atrial fibrillation)?
Yes No

Do you or anyone in your immediate family have a history of diabetes?
Yes No

Do you or anyone in your immediate family have a history of cancer?
Yes No

Does anyone in your immediate family have a history of Stroke, transient ischemic episodes, or cognitive decline (Alzheimer’s disease, dementia)?
Yes No

Do you or anyone in your immediate family have a history of arthritis?
Yes No

Do you take any of the following medications:
Cholesterol lowering drugs (statins such as Lipitor, Zocor, Lescol, Provachol, Mevacor)?
Yes No

Antibiotics (penicillin, tetracycline)?
Yes No

Analgesics (aspirin, ibuprofen, naprosyn)?
Yes No

Oral contraceptives?
Yes No

Asthma medications (steroids such as prednisone, asmacort)?
Yes No

Antihypertensive medications (diuretics, ACE inhibitors, calcium channel blockers)?
Yes No