How toxic is your lifestyle?

• Often
• Once a day
• Few times per week
• Once a week
• Almost Never

• Never
• Once a Week
• Once a Day
• 2+ Times per Day

• 1 per Month
• 1 per Week
• 1 per Day
• 3 per Day
• 5+ per Day

• Almost Never
• Once a Week
• 3 Times per Week
• At Least Once a Day

• None
• 1 per Day
• 4 per Day
• 8 per Day
• 10+ per Day

• 3+ Times per Day
• Once a Day
• Few Times per Week
• Almost Never

• 12+ per Week
• 8 per Week
• 4 per Week
• 2 per Week
• Almost Never

• Almost Never
• Once a Week
• Few times per week
• Daily

• Almost Never
• Once a Week
• Few times per week
• Daily

• Almost Never
• Once a Week
• 3 Times per Week
• 5+ Times per Week

• Most Times
• 50% Of The Time
• Almost Never
• I don't exercise

• Almost Never
• Sometimes
• Usually
• Always

• Once a Week
• Every 4 days
• Every 2nd day
• Daily
• 2+ times per day

• +2 hours
• 2 hours
• 90 minutes
• 60 minutes
• 30 minutes

• Most of the time
• 50% of the time
• Almost Never

• Most of the time
• 50% of the time
• Almost Never

• 8+ hours per day
• 6+ hours per day
• Few hours per day
• Almost Never

• All Day
• Few times per day
• Few times per week
• Almost Never

Is there a history of any of the following illnesses in your immediate biological family (grandparents, parents, siblings or children)?

• Cancer, diabetes, heart disease, depression, obesity, liver disease, as rheumatoid arthritis, lupus, psoriasis, or type 1 (early-onset) diabetes, high cholesterol, high blood pressure, auto-immune conditions such

• 2 or more
• 1
• None

• Cancer, diabetes, heart disease, depression, liver disease, high cholesterol, high blood pressure

• 2 or more
• 1
• None

• Headache, fever, sore throat, muscle aches (not exercise-induced), colds or flu,rash, swelling, indigestion (heartburn or bloating)

• Once a Day
• Once a Week
• Once a Month
• Almost never

• 3+ fillings
• 2 fillings
• 1 filling
• Never

• 5+ times per week
• 3 times per week
• Once per week
• Never

• Very high
• High
• Moderate
• Slight
• Almost None

• 2+ times per day
• Once a day
• Once a week
• Once a month
• Never