EXERCISE CALORIES BURNED

USA CAUSES OF DEATH

SEX ADDS YEARS TO LIFE

DYING OF A BROKEN HEART

Your Email Address:

    Your Name:

LIFE EXPECTANCY TEST:

ENTER DOB AND GENDER: PRESS START   MM 01 02 03 04 05 06 07 08 09 10 11 12 DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 YYYY 200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900 Gender ---------- Male Female Coronary Artery Disease (CAD) Cholesterol Select one ---------- under 160 160-200 200-220 220-240 over        Blood Pressure Select one ---------- 110 / 60-80 110-130 / 60-80 130-150 / 80-90 150-170/ 90-100 170 / 100        Smoking Select one ---------- never quit 10 years quit < 10 years 2nd hand smoke occasional 1 pack daily 2 packs daily        Family History Heart Select one ---------- No history 1 close relative 60+ 2 close 60+ 1 close <60 2 close <60        Body Fat Select one ---------- very Lean lean average above average obese        Stress Level Select one ---------- no stress occasional mild frequent mild frequent high constant high        Physical Activity Select one ---------- female under 45 years female over 45 years male stocky male bald, stocky male Select one ---------- daily intense daily moderate moderate light sedentary        Medical Medical Exams Select one ---------- regular exam periodic exam infrequent tests no exams        Long-term Medications Select one ---------- None Brain Cardiovascular Cholesterol        Family History Cancer Select one ---------- no history some history chronic history        Lung Select one ---------- no problems emphysema chronic problems        Digestive Tract Select one ---------- no problems occasional diarrhea frequent diarrhea frequent indigestion ulcers severe causes        Diabetes Select one ---------- no history hypoglycemia Type II Type I        Recreational Drugs Select one ---------- no use seldom use regular use heavy use        Personal Longevity Select one ---------- parents lived 90 parents lived 80 parents lived 70 parents lived 60 parents lived 50        Race Select one ---------- White Asian Hispanic Black Indian        Education Select one ---------- college degree some college trade school high school grade school        Sleep Select one ---------- 7-9 hours 6-7 hours <6 hours >9 hours        Dietary Diet Select one ---------- low-fat moderate fat typical fat few fruits/vegetables fad diet        breakfast Select one ---------- daily sometimes none coffee only heavy sugar        Regular meals Select one ---------- 3 or more 2 daily not regular starve and stuff        Alcohol Select one ---------- none 1 drink daily 2 drinks daily 3-6 drinks daily more than 6        Psychological Happiness Select one ---------- very happy normal unsure about life often unhappy always unhappy        Depression Select one ---------- no history some history depressed life not worth living thoughts of suicide        Anxiety Select one ---------- seldom occasionally often always panic attacks        Relaxation Select one ---------- daily often seldom usually tense always tense        Love Select one ---------- happily married unhappily married affair single separated, divorced widowed        Social Select one ---------- many friends some friends no close friends unhappy with friends reclusive        Job satisfaction Select one ---------- enjoy job job ok dislike job hate job        Safety Driving Miles/yr Select one ---------- less than 4,000 4,000-12,000 12,000-20,000 more than 20,000        Seat belt usage Select one ---------- always sometimes (25%) never        Occupational Risk Select one ---------- not dangerous somemtimes dangerous occasional very dangerous extremely dangerous        Recreational Risk Select one ---------- never slightly occasionally very extreme        HEALTH AGE SCORE Average LifeX Your LifeX REAL AGE HEALTH AGE TEST COMPLETE! Your itemized scores (years) CAD Medical Personal Diet Mental Safety TOTAL This questionnaire is designed to help make you aware of factors that can effect your health and longevity. Review your answers and determine which factors you can improve. Geographic Location What Country do you live in? Select one ---------- Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Central African Republic Chad Chile China Colombia Comoros Congo Cook Islands Costa Rica Côte d'Ivoire Croatia Cuba Cyprus Czech Republic Democratic People's Republic of Korea Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran (Islamic Republic of) Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Lithuania Luxembourg Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia (Federated States of) Monaco Mongolia Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Niue Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Republic of Korea Republic of Moldova Romania Russian Federation Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syrian Arab Republic Tajikistan Thailand The former Yugoslav Republic of Macedonia Timor-Leste Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United Republic of Tanzania United States of America Uruguay Uzbekistan Vanuatu Venezuela (Bolivarian Republic of) Viet Nam Yemen Zambia Zimbabwe

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