1. Would you say that your health in general is ....
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2. Do you currently smoke cigarettes, cigars, pipes or hookah?
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3. Do you currently use smokeless tobacco (i.e., dip snuff)?
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4. How many alcoholic beverages do you have during a typical day when you drink
alcohol? (One drink = 12 ounces of regular beer, 5 ounces of wine, 1.5 ounces of
80-proof distilled spirits)
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5. How often do you typically drink 5 or more alcoholic drinks on one occasion?
("One Occasion" refers to an event or period when drinking exceeds one drink per
hour)
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6. How often do you drive when perhaps you have had too much to drink?
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7. In general, how satisfied are you with your life?
(i.e., work situation, social activity, accomplishing what you set out to do)
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8. How often do you feel that your work situation is putting you under too much
stress?
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9. How often do you have someone to talk to when you are feeling lonely, depressed,
angry, or in need of help?
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10. On average, how many weeks per month do you engage in a total of at least 150
minutes of moderate-intensity aerobic activity (moderate-intensity physical activity
means working hard enough to raise your heart rate and break a sweat, yet still
being able to carry on a conversation. i.e., brisk walking, swimming leisurely,
or leisurely biking) OR at least 75 minutes of vigorous intensity aerobic
activity? (vigorous-intensity means you will not be able to say more than a few
words without pausing for a breath, i.e., jogging/running, swimming laps, or jumping
rope)
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11. On average, how many days per week do you engage in muscle-strengthening actvities
that work all muscle groups
(legs, hips, back, abdomen, chest, shoulders and arms)?
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12. How often do you usually eat high-fat foods?
(i.e., fried foods; high-fat dairy products such as butter, cheese, or whole milk;
or packaged foods high in fats)
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13. About how many cups of fruit do you eat each day?
(One cup of fruit = one small piece of fruit, one cup of cut-up fruit, one cup of
100% fruit juice, or 1/2 cup of dried fruit)
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14. How often do you use over the counter (OTC) drugs, dietary supplements, or herbal
products to help you manage your weight, enhance athletic performance, or treat
depression?
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15. How frequently do you floss your teeth?
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16. About how many cups of vegetables do you eat each day?
(One cup of vegetables = 1 cup of raw or cooked vegetables, 1 cup of 100% vegetable
juice, or 2 cups of raw leafy greens)
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17. How often do you get enough restful sleep to function well in your job and personal
life?
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