Health Age Questionnaire

Personal

Sex	Select one ---------- female male
Race	Select one ---------- white black Hispanic Asian American Indian other
Longevity	Select one ---------- grandparents lived past 90, parents past 80 grandparents lived past 80, parents past 70 grandparents lived past 70, parents past 60 few relatives lived past 60 few relatives lived past 50
Education	Select one ---------- college graduate or skilled craftsman some college or trade school high school graduate grade school graduate
Sleep	Select one ---------- 7-8 hours 8-9 hours 6-7 hours more than 9 hours less than 6 hours

Coronary Artery Disease (CAD)

Cholesterol (or total cholesterol / HDL ratio)	Select one ---------- under 160 (< 3) 160-200 (3-4) 200-240 (4-5) 240-280 (5-6) over 280 (> 6)
Blood pressure (systolic / diastolic)	Select one ---------- < 110 / 60-80 110-130 / 60-80 130-150 / 80-90 150-170/ 90-100 > 170 / > 100
Smoking	Select one ---------- never quit more than 10 years ago quit less than 10 years ago around others who smoke occasional 1 pack cigarettes daily 2 or more packs daily
Heredity	Select one ---------- no family history of CAD 1 close relative over 60 with CAD 2 close relatives over 60 with CAD 1 close relative under 60 with CAD 2 or more close relatives under 60 with CAD
Waist / Hip Ratio (Instructions)	Select one ---------- low risk (< 0.84 male; < 0.72 female) moderate risk (<0.94 male; <0.82 female) high risk (< 1.04 male; <0.92 female) very high risk (>1.04male; >9.2 female)
Stress	Select one ---------- unhurried, happy ambitious but relaxed sometimes competive or time conscious competitive and time consious (type A) type A with repressed hostility
Physical activity (work, recreation, and exercise)	Select one ---------- 60 min, high intensity, most days 30 min, moderate, most days 20-30 min, moderate, 3-5 days/wk 10-20 min, light, 1-2 days/wk sedentary

Medical

Medical exam and screening tests (blood pressure, glaucoma, diabetes)	Select one ---------- regular medical exam and tests periodic medical exam sometimes get tests no tests or medical exams
Heart	Select one ---------- no history of problems self or family some history rheumatic fever as child, no murmur now rheumatic fever as child, have murmur EKG abnormality or angina
Lung (including tuberculosis and pneumonia)	Select one ---------- no problems some past problem mild asthma or bronchitis emphysema, severe asthma, or bronchitis severe lung problems
Digestive tract	Select one ---------- no problems occasional diarrhea, loss of appetite frequent diarrhea or stomach upset ulcers, colitis, gall bladder, or liver problems severe gastrointestinal disorders
Diabetes	Select one ---------- no problem and no family history no problem but family history controlled hypoglycemia (low blood sugar) hypoglycemia and family history mild diabetes (diet and exercise) diabetes (insulin)
Drugs	Select one ---------- seldom use minimal but regular use of aspirin or other medications heavy use of aspirin or other medications regular use of drugs heavy use of drugs

Medical (women only)

Women's health care	Women only ---------- Regular Pap and breast exam occasional Pap and breast exam never have exam treated disorder untreated cancer
Birth control pill	Women only ---------- never used quit 5 years ago still use, under 30 years of age use pill and smoke use pill, smoke, over 35

Dietary

Breakfast	Select one ---------- daily sometimes none coffee coffee and doughnut
Regular meals	Select one ---------- 3 or more 2 daily not regular starve and stuff
Fruits and vegetables	Select one ---------- 5 or more full servings daily 2-4 servings daily 1 or less servings daily don't eat them
Fats	Select one ---------- mostly nuts, olive oil, fatty fish, and lean proteins low saturated and unsaturated fats both saturated and unsaturated fats very low carbohydrate diet with saturated fats mostly meats, whole milk, cheese, or fried foods
Refined foods	Select one ---------- no refined foods some refined foods several servings: bread, rice, cereals, packaged foods several servings: sugar, soft drinks, sweets, snack foods
Alcohol	Select one ---------- none 1 drink daily 2 drinks daily 3+ drinks, periodically 3-6 drinks daily more than 6 drinks daily

Psychological

Happiness	Select one ---------- generally feel very happy feel satisfied unsure about life often unhappy usually unhappy
Depression	Select one ---------- no family history of depression some family history, I feel OK family history and I am mildly depressed sometimes I feel life isn't worth living thoughts of suicide
Anxiety	Select one ---------- seldom anxious occasionally anxious often anxious always anxious panic attacks
Relaxation	Select one ---------- relax or meditate daily relax often seldom relax usually tense always tense
Love and marriage	Select one ---------- happily married married unmarried separated, divorced, or widowed extramarital relationship
Job satisfaction	Select one ---------- enjoy job, see results, able to advance job OK, no results, nowhere to go dislike job hate job
Social	Select one ---------- have some close friends have some friends have no good friends stuck with people I don't enjoy do not have friends

Safety

Driving	Select one ---------- less than 7,000 miles (11,000 km) / year 7,000-15,000 miles (11,000-24,000 km) / year 15,000-20,000 (24,000-32,000 km) miles / year more than 20,000 miles (32,000 km) / year
Seat belt usage	Select one ---------- always most of the time (75%) on highway only sometimes (25%) never
Risk-taking (motorcycle, mountain climb, skydive, higher risk job, etc.)	Select one ---------- never some with careful preparation occasional often try anything for thrills

Type your actual age here

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Typical Life Expectancy*

Your Life Expectancy

Your Health Age

This questionnaire is designed to help make you aware of factors that can effect your health and longevity. Review your answers and determine which factors you can improve. *Typical Life Expenctancy based on 2002 US Statistics for all races and sexes.

Your itemized scores (years)

Personal

Medical

CAD

Diet

Psychological

Safety

Total