Do you experience any digestive issues such as bloating, gas, diarrhea, heartburn, or pain in the belly?
Yes, frequently
Yes, occasionally
No, hardly ever
How often do you have a bowel movement?
At least once a day
Once every two days
Once every three or more days
Do you feel happy and satisfied?
Yes, most of the time
Yes, some of the time
No, hardly ever
Do you worry or feel anxious?
Yes, frequently
Yes, some of the time
No, hardly ever
How often do you do relaxation exercises such as meditation, yoga, deep breathing
Never
At least three times/week
Daily
Do you suffer from painful joints, psoriasis, or eczema?
Yes, frequently
Yes, some of the time
No, hardly ever
Do you use acid–blocking medication to treat heartburn (examples: Nexium, Prilosec, Prevacid, Dexilant)?
yes
no
Do you have difficulty falling asleep or staying asleep?
Yes
No
How often do you do weight-bearing exercise (walking, dancing, jogging, aerobic exercises) for at least 30 minutes a day?
Once a week or less
At least twice a week
At least three times a week
How often do you do resistance or strength training exercises?
Never
Once a week
At least twice a week
How physically active is your day?
Not active – I spend most of the day sitting or lying down
Moderately active – I sit for part of the day, but make sure to be active the rest
Very active – I am always on the move
How often do you eat or drink sugary foods or beverages?
Daily
Couple times per week
Rarely – once or twice a month
How many ½ cup servings of fruits and vegetables do you consume per day?
One or less
Two to four
Five or more
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