HEALTH QUESTIONNAIRE

Is health related to lifestyle habits? Let’s find out! Answer a few questions about your habits and your state of health, and we will tabulate and post your statistics anonymously with the others who have also completed the survey.

Please rank the importance to you of your top 4 of the following 8 food groups: (One entry per column)

Food Group
Number 1

Number 2

Number 3

Number 4

Industrial starches (white bread, white rice, pasta, boxed cereal, cake, cookies, pizza, flour tortillas)

Traditional starches (beans, whole grains, potatoes and other tubers, winter squash)

Meat and dairy products (meat, milk, eggs, cheese, fish, butter, cream)

Nuts, seeds, avocados, durian, olives, coconut, and other oil-rich plant foods.

Canned or thoroughly cooked vegetables

Salad and fresh vegetables

Candy and sweet or alcholic drinks (candy, dried fruit, soda, juice, coffee, tea, beer, wine, liquor (any of these))

Fresh fruit

How much time per day do you spend in prayer or meditation?
None.
15 minutes or more
30 minutes or more
An hour or more

How much time per week do you spend engaging in physical exersize? (walking, running, dancing, playing sports, practicing martial arts or hatha yoga, gardening or physical labor)
Not at all
Less than an hour
1 hour or more per
3 hours or more
7 hours or more

How do you feel?
Very happy.
Angry
Lonely.
Worried.
In pain.

How physically fit are you?
I can walk or dance for hours.
A little out of shape.
Overweight and out of shape.

If you give us your name, email and birth decade, your statistics will be counted:

Name:

E-mail address:

Decade of birth:

Thank you for completing our Health Questionnaire!

Here is a partial breakdown of the responses from participants so far:

Out of a total of 2 respondents, 2 reported feeling very happy. Of these:
	Approximate Age
Preferred Food Group	20	30	40	50	60	70	80	Total
Industrial Starches	0	0	0	0	0	0	0	0
Traditional Starches	0	0	0	0	1	0	0	1
Meat and Dairy	0	0	0	0	0	0	0	0
Nuts and Oily Fruit	0	0	0	0	0	0	0	0
Cooked Vegetables	0	0	0	0	0	0	0	0
Salad	0	0	0	1	0	0	0	1
Candy and Sweet Drinks	0	0	0	0	0	0	0	0
Fresh Fruit	0	0	0	0	0	0	0	0

Out of a total of 2 respondents, 2 reported being physically fit enough to walk or dance for hours. Of these:
	Approximate Age
Preferred Food Group	20	30	40	50	60	70	80	Total
Industrial Starches	0	0	0	0	0	0	0	0
Traditional Starches	0	0	0	0	1	0	0	1
Meat and Dairy	0	0	0	0	0	0	0	0
Nuts and Oily Fruit	0	0	0	0	0	0	0	0
Cooked Vegetables	0	0	0	0	0	0	0	0
Salad	0	0	0	1	0	0	0	1
Candy and Sweet Drinks	0	0	0	0	0	0	0	0
Fresh Fruit	0	0	0	0	0	0	0	0

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