NOTE: If the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) applies to you and your intended use of SurveyMonkey, this template is NOT intended for your use without 1) a SurveyMonkey ‘HIPAA-enabled’ account, and 2) a business associate agreement with us, which can be purchased by contacting our sales team. Please see our Acceptable Uses Policy for more information.

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1. In general, how would you rate your overall health?

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2. What is your height in feet and inches? For example, if you are 5 feet and 4 inches, write 5’4”.

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3. What is your current weight in pounds?

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4. Do you currently smoke cigarettes, or not?

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5. About how many alcoholic drinks do you have each week?

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6. How many hours do you sleep each night?

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i We adjusted the number you entered based on the slider’s scale.

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7. About how many times in the average week do you engage in 30 minutes of light activity (i.e. leisurely walking, gardening, cleaning around the house)?

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8. About how many times in the average week do you engage in 30 minutes of moderate activity (i.e. brisk walking, light bicycling)?

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9. About how many times in the average week do you engage in 30 minutes of strenuous activity (i.e. running or jogging)?

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10. How often do you use sunscreen while out in the sun?

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