Lifestyle Questionnarie
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1
Participant Info
2
Physical Activity
3
Diet & Alcohol
4
Health
5
Sleep, Stress, Social Support
Full Name
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Email
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Clinic name
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Patient ID
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Ethnicity
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Asian
Black
White
Native
Unknown
Date of Birth
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MM slash DD slash YYYY
Sex
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Male
Female
Intersex
Prefer not to say
Height
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Weight
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In a typical week, how many times do you exercise?
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0
1-2
2-5
6-7
7
On average, how many minutes of physical exercise do you get daily?
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Less than 20 mins
30-60 mins
60-90 mins
More than 90 mins
Which of the following types of exercise do you practice?
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Strength Training
Weight Lifting
Stretching
> HIIT
Yoga
Balance Training
On average how many meals do you eat daily (excluding snacking)?
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1
2
3
4
5 or more
Do you practice intermittent fasting?
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Yes
No
I don’t know what that is
Do you practice intermittent fasting?
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0-1
2-3
4-5
6+
Do you follow a specific diet?
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Low Calorie
Paleo
Pescatarian
Vegetarian
Vegan
Ketogenic
Gluten Free
Low Carb
None
Are fermented foods regularly included in your diet?
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Yes
No
Maybe
How often do you eat red or processed meat?
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Never
Less than once per week
1-2 times per week
3-4 times per week
5-6 times per week
More than 6 times per week
I’m not sure
How much water do you drink daily?
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0.5L
0.5-1L
1-1.5L
More than 1.5L
On average, how many cans/bottles of soft drinks do you consume daily?
0
1-2
2-3
3-4
5 or more
Alcoholic drinks per week (1 drink = 5 oz wine / 12 oz beer / 1.5 oz spirits)
0
1-7
8-14
More than 14
Please list any supplements you are taking
Add
Remove
Would you say that in general your health is…
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Excellent
Very Good
Good
Fair
Poor
Do you have any allergies?
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Yes
No
Maybe
Have you had cavities, gingivitis or periodontitis within the past year?
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Yes
No
Within the past 2 months, have you had gastrointestinal conditions or discomfort, such as bad breath, gastric acidity, flatulence and / or feeling bloated after a meal, diarrhea, very soft stools, constipation or hemorrhoids?
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Yes
No
If you answered yes, please list which one you had:
Add
Remove
Do you frequently have musculoskeletal pain?
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Yes
No
Within the past 2 months have you had memory problems, mood swings, felt depressed or anxious?
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Yes
No
Do you have any diagnosed medical condition?
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Yes
No
If you answered yes, feel free to be specific:
Have you previously used tobacco or e‑cigarettes?
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Yes
No
Do you currently use tobacco or e‑cigarettes?
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Yes
No
Have you ever been diagnosed with, or treated for, any of the following conditions?
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Yes
No
Lupus
Rheumatoic Arthritis
Multiple Sclerosis
Immunodeficiency
Diabetes
Thyroid Disease
Heart Failure
Coronary Artery Disease
If you answered any question with yes, do you take any medications for your illness/es?
Yes
No
Please list your medication
Add
Remove
On average how much sunlight exposure you get daily?
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Less than 30 mins
1h
2h
3h or more
What personal support do you have in your life?
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Community
Big Social Circle
Close Friends/Family
I feel somewhat lonely
I prefer to be alone
Do you feel stressed?
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All the Time
Most of the Time
Sometimes
Rarely
Average hours of sleep per night
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Less than 6h
6h
7h
8h
More than 9h
What is the level of exposure to air pollution where you live?
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Good
Moderate
Unhealthy
Very unhealthy
Hazardous
Comments
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