5) Genetics & Lifestyle Name Family Member Age Diseases If Deceased, Cause of Death Age at Time of Death Cigarettes --- Never Stopped Yes Quit date How many years did you smoke? Packs per day? Other tobacco Pipe Cigar Snuff Chew n/aDo you drink alcohol? --- Never Not any more Yes If Yes, number of drinks per week Do you use marijuana or recreational drugs? --- No Yes Have you ever used needles to inject drugs? --- No Yes Do you use any drugs or medicines to go to sleep, relax, calm down, or lose weight? --- No Yes Do you exercise regularly? --- No Yes If Yes, what kind of exercise? How long (minutes)? How often? Do you think you need to lose or gain weight? How many hours do you sleep most nights? What time do you go to sleep? Do you sleep soundly? How often do you use sleep aids? When do you feel your best? When do you feel your worst? When do you have the least amount of energy? How do you feel when you wake up in the morning? Have you had an extended period of feeling depressed or down? --- No Yes If Yes, please describe How would you rate your current diet? --- Good Fair Poor Have you significantly changed your diet in the past year? --- No Yes If so, how? How much bread do you eat on an average day? Do you eat fresh fruits and vegetables every day? --- No Yes How many servings daily? Do you limit the amount of processed food, especially fried or fast foods, that you eat? --- No Yes Do you read ingredient labels? --- No Yes What ingredients do you avoid? Do you drink at least 6 - 8 glasses of water daily? --- No Yes Do you filter your drinking water? --- No Yes Do you filter your bath water? --- No Yes Do you eat organic or follow the Clean 15 / Dirty Dozen guidelines? --- No Yes Do you exclude foods containing GMO's and animal products that were fed GMO feed? --- No Yes Do you consume dairy regularly (milk, cheese, yogurt, ice cream, butter, whey protein)? How much meat do you eat (ounces) in an average day? What sweets do you eat often? Do you use aspartame (NutraSweet), Splenda, or Sweet and Low? --- No Yes Have you ever been tested for food allergies? --- No Yes Have you ever been tested for celiac disease or gluten sensitivity? --- No Yes How many bowel movements do you have each day? Have you been exposed to any of the following? Pesticides Mold Heavy metals Radiation Electric / Magnetic fields (EMF's) Asbestos Excessive secondhand smoke n/aEnter Code Powered by ChronoForms - ChronoEngine.com
