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1. Patient Name:

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2. Date of Birth:

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3. Employer

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4. Mark all of the following that you are being treated for, taking medication for or have been diagnosed with:

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5. Number of prescribed and/or over-the-counter medications you currently take

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6. In general, how would you rate your health?

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7. In general, how many days do you get at least 30 minutes of exercise each week?

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8. Do you plan to increase your exercise in the next 3 months?

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9. In general, how many servings of fruits and vegetables do you get in a typical day?

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10. Do you have plans to increase your fruits and vegetables in the next 3 months?

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11. Do you use tobacco products?

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12. Current/Former Smokers:

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13. How many cups of coffee or caffeinated beverages do you normally consume daily?

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14. How many 8 ounce glasses of water do you normally drink daily?

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15. Do you consume alcohol?

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16. How many drinks per week?

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17. How often do you feel stress in your life?

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18. What do you consider the main source of your stress?

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19. During the past year, how often have you felt tense, anxious or depressed?

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20. How many hours of sleep do you get each night?

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21. Do you have any of the following symptoms?