Lifesprung questionnaire

What is your:

Age? *

Height? *

Weight? *

(pounds) Choose the closest value to your actual weight.

BMI

Final result

Do you drink more than 21 drinks per week?

(one beer, one glass of wine or an ounce of liquor are all considered one drink)

Drinks

Yes No

Drinks_result

Have you had more than one moving violation while driving in the past 12 months?

Moving violations

Yes No

Moving_violation_result

Do you currently work full-time (at least 30 hours per week)?

Work full-time

Yes No

Fulltime_result

Have you ever been diagnosed or treated for:

Diabetes?

Yes No

Diabetes_result

Multiple sclerosis?

Yes No

Multiple_sclerosis_result

Cancer?

Yes No

Cancer_result

Have you ever been diagnosed or treated for:

Kidney disease?

Yes No

Kidney_disease_result

Heart disease?

Yes No

Heart_disease_result

Liver disease?

Yes No

Liver_disease_result

Have you ever been diagnosed or treated for:

High blood pressure?

Yes No

High_blood_pressure_result

Is your blood pressure currently in the normal range?

Yes No I Don't Know

High cholesterol?

Yes No

High_cholesterol_result

Is your cholesterol currently in the normal range?

Yes No I Don't Know

Depression or anxiety?

Yes No

Depression_result

Have you ever been admitted to a hospital for depression or anxiety?

Yes No

Have you had more than two episodes of depression or anxiety that required treatment in the past two years?

Yes No

Has your depression or anxiety ever caused you to become unemployed?

Yes No

Have 2 or more of your parents or siblings been diagnosed before the age of sixty with:

Stroke?

Yes No

Stroke_result

Heart disease?

Yes No

Heart_disease_result

Cancer?

Yes No

Cancer_result

Are you currently getting paid to engage in any of the following occupations?

Check all that apply.

*

Commercial pilot Scuba diver Off-shore rig worker Boxer or martial artist Handler of explosives Handler of dangerous chemicals Stunt professional

Occupations_result

None of the above

Do you, or are you planning to engage in any of the following activities?

Check all that apply.

*

Skydiving or base jumping Flying a private plane Scuba, cave, cliff or wreck diving Backcountry skiing Hang gliding Mountain climbing Car or motorcycle racing

Activities_result

None of the above