Lifestyle

In this section we'll discuss the various aspects of your lifestyle

What types of exercise do you engage in?

Please describe the frequency (# of days per week) and duration (minutes) of any forms of exercise here. Ex: "Yoga, twice a week, 60 minutes)

Yoga, twice a week, 60 minutes

Does anything limit you from being physically active?

I am physically active.

Stress level of the various stressors

	Not a stressor	low	moderate	high	very high
Work
Family
Social
Financial
Health
Others

Please list any other stressors and their severity:

It is a long established fact that a reader will be distracted by the readable content of a page when looking at its layout. It is a long established fact that a reader will be distracted by the readable content of a page when looking at its layout.

What helps you unwind?

It is a long established fact that a reader will be distracted by the readable content of a page when looking at its layout.

On weeknights, on average how many hours of sleep do you get?

On weekend nights, on average how many hours of sleep do you get?

Do you smoke or use tobacco?

Never

In the past

Occasionally, less than once a month

Once a week

Daily, once or twice

Daily, more than twice a day

Other

Preferred method of smoking.

Cigarettes Cigars Pipe Chewing tobacco Pouches Other

Do you use recreational drugs?

I don't feel comfortable discussing

Never

In the past

Occasionally, less than once a month

Once a week

Daily, once or twice

Daily, more than twice a day

Other

Preferred method of smoking.

Marijuana Cocaine Other

Do you drink alcohol?

Never

In the past

Occasionally, less than once a month

Once or twice a week, one or two drinks

Once or twice a week, more than two drinks

Every day, one or two drinks

Every day, more than two drinks

Other

Types of alcohol you usually consume.

Beer Wine Liquor Other

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What types of exercise do you engage in?

Yoga/Stretching Cardio/Aerobics (walking, jogging, biking, etc.) Strength-training (weight lifting, pilates) Sports Other

Please describe the frequency (# of days per week) and duration (minutes) of any forms of exercise here. Ex: "Yoga, twice a week, 60 minutes)

Does anything limit you from being physically active?

Stress level of the various stressors

	Not a stressor	low	moderate	high	very high
Work
Family
Social
Financial
Health
Others

Please list any other stressors and their severity:

What helps you unwind?

On weeknights, on average how many hours of sleep do you get?

On weekend nights, on average how many hours of sleep do you get?

Do you smoke or use tobacco?

Never

In the past

Occasionally, less than once a month

Once a week

Daily, once or twice

Daily, more than twice a day

Other

Preferred method of smoking.

Cigarettes Cigars Pipe Chewing tobacco Pouches Other

Do you use recreational drugs?

I don't feel comfortable discussing

Never

In the past

Occasionally, less than once a month

Once a week

Daily, once or twice

Daily, more than twice a day

Other

Preferred method of smoking.

Marijuana Cocaine Other

Do you drink alcohol?

Never

In the past

Occasionally, less than once a month

Once or twice a week, one or two drinks

Once or twice a week, more than two drinks

Every day, one or two drinks

Every day, more than two drinks

Other

Types of alcohol you usually consume.

Beer Wine Liquor Other

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