1.   Please state your age (R)

        18-25
        26-34
        35-44
        45-54
        55 --64
        more than 64

2.   Please state your sex. (R)

        Male
        Female

3.   Please give a broad idea of the work you do (R)

        Professional and sedentary work
        Hard Manual Labour
        Agent selling things home to home
        Call center worker
        Service Industry Employee
        Unemployed
        Other

4.   Describe yourself (R)

        Thin and gangly
        Average, albeit on the thinner side
        Average, medium build
        Average, but a little portly
        Overtly fat, but not obscenely so
        Shish, don't tell anyone ! I am really fat!
        Fat, but fit, like a Sumo Wrestler

5.   Have you had any of these before or are having it now? (R)

        Angina
        High Blood Pressure
        Transient spells of weakness of hands or legs or both
        Diabetes Mellitus
        Giddiness and Falls for no apparent reason
        Numbness of fingers/toes or cramps in legs
        None of the above

6.   Family History (R)

      Many in my family had/have heart problems/stroke My parent(s) had/have ischemic heart disease My parent(s) had/have brain stroke My brother(s)/sister(s) have a positive history Just one or two members have history of heart /neuro problems No positive family history No positive history, and some/ all drink &/or smoke

7.   Do you smoke? (R)

        I am a chain smoker(>20 cigarettes/day)
        I am a daily heavy smoker(>10, <20)
        I am a daily regular smoker(<5/day)
        I smoke 1-2 sticks daily
        I smoke not more than 5 sticks in a week
        I smoke infrequently
        I do not smoke

8.   Click which one best describes your habits (R)

        I drink heavily, and sometimes lose my senses
        I drink more than 3 pegs daily
        I drink 1-2 pegs daily
        I drink infrequently
        I drink rarely
        I never drink

9.   If you drink, then answer this question

        Whisky/Gin/Vodka/Rum
        White Wine
        Red Wine
        Beer
        Others

10.   If you do any other substances, write about it

     

11.   Tick the line that best describes you (R)

        I am a glutton, who sees what one eats!
        I eat heavily, and it shows on me
        I eat well, and I enjoy cakes and burgers
        I eat moderately, but gimme those fries,lol!
        I eat modestly, and watch what I am having
        I eat modestly, and count calories
        I skip meals to keep slim!

12.   What are your physical activities? (R)

        I run more than 3 miles daily
        I exercise 45 minutes everday
        I participate in action sports 3-4 times a week
        Gym for me , 5 days a week, 2 hrs daily
        Modest Exercise, half of a or b above
        Minimal exercise
        None at all..oh sorry, I do press elevator and remote buttons!

13.   Tell us about your sex-life (R)

        Have it regularly and enjoy it!
        Have it occasionally.
        Zilch, zip,nada.
        What's it to you?

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