How old are you?
Child (under 12)
Teenager (13-18)
Adult (over 18)
How much sleep do you usually get?
under 5 hours
5-7 hours
8-10 hours
over 10 hours
How much physical activity do you usually get?
1 hour a week
2-5 hours a week
1 hour a day
over 1 hour a day
Rate your level of stress:
low
moderate
high
How many servings of fruits and vegetables do you have daily?
less than 1
1-2
2-4
over 4
Do you sleep and eat on a regular schedule?
never
sometimes
always
Do you see a dentist or physician regularly?
on a scheduled basis
