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* 1. What is your first and last name? (Must complete in order to receive credit for HSA contribution)

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* 2. What is your email address?

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* 3. How often do you participate in at least 30 minutes of moderate exercise?

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* 4. How many servings of fruits and vegetables do you eat each day?
Example of 1 serving: 1 cup leafy greens or 1 medium piece of fruit. 

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* 5. Which of the following beverages do you drink regularly? (check all that apply)

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* 6. How often, on average, do you consume any of the following foods?
  •  pastries such as cakes, croissants, turnovers
  •  cookies 
  •  rich desserts
  •  premium ice cream
  •  donuts
  •  high fat muffins

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* 7. How often, on average, do you consume any high fat snack foods (e.g., potato chips, nachos, any fried chips, chocolate bars, etc.?)

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* 8. Do you drink at least 64 ounces of water each day?

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* 9. Do you think you get adequate sleep each night?

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* 10. On average, how many hours of sleep do you get each night?

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* 11. Have you used Tobacco products in the last 12 months?

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