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• Age
  
  
  
• Height (in inches)
  
  
  
• Weight (in pounds)
  
  
  
• About how many hours per night do you sleep?
  
  
  
• Glasses of water per day?
  
  
  
• Do you smoke tobacco products?
  
  Yes No
  
  
• If so, how many packs per week?
  
  
  
• How have you been feeling over the past week?
  
  Happy Satisfied Ambivalent Uneasy Depressed
  
  
• Hours of exercise per week?
  
  
  
• Alcoholic drinks per week?
  
  
  
• Servings of meat per week?
  
  
  
• Servings of refined sugars/oils per week?
  
  
  
• Resting heartrate (in BPM)?