Healthy Lifestyle & Fitness Survey

1. Sex: Male or Female? M__ F__
2. What is your Age? ___
3. What is your present height? ___
4. What is your present weight? ___
5. Do you smoke? ___
6. Do you drink alcohol? ___
7. Do you exercise at least 3 to 5 times a week? ___ or more? ___
8. Do you take a daily multivitamin? ___
9. Do you drink a minimum of 1 liter of water per day? ___
10. Do you take fitness and nutritional supplements? ___
11. Does any member of your immediate family have high blood pressure? ___
12. Does any member of your immediate family have diabetes? ___
13. Do you feel you have a stressful lifestyle? ___
14. Are you employed? ___
15. Are you self emplyed? ___
16. Are you in school? ___
17. Do you have a bank account? ___
18. Do you have a credit card? ___
19. Do you do something for yourself and have fun at least 3 times a week? ___
20. Do you love life? ___
21. What is your nationality? ______