L.I.F.E. Questionnaire

Pregnant or nursing:

Female only: Are you pregnant or nursing?

Personal Information

Birthdate January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Gender male female Height 3' 4' 5' 6' 7' 0'' 1'' 2'' 3'' 4'' 5'' 6'' 7'' 8'' 9'' 10'' 11'' Weight (lbs)

Please check the box if you consume the following item:

Soda or carbonated beverages of any kind including carbonated water? White flour products? Fried foods? Sugars other than fructose, sucanat, stevia, or raw organic honey? Artificial sweeteners? Candy? Red meat or pork? Tap water? Drinks containing caffeine, such as coffee and tea? Alcoholic beverages? Artificial colors, flavoring, MSG or preservatives (BHT, etc.) Hydrogenated or partially hydrogenated oils? Any tobacco products? Are you a vegetarian? Fifty percent of your food in its raw form? Eight to ten glasses of water daily? Real butter as opposed to margarine? Oils in the form of extra virgin olive oil and safflower or canola oil daily? One Tbsp. of freshly ground flax seeds or hulled hemp seeds daily? At least 6 servings of whole grains daily? (serving size: 1 piece of bread or 3/4 cup oatmeal) At least 3-4 servings of fresh fruit daily? (serving size: 1/2 cup chopped) At least 3-6 servings of fresh vegetables daily? (serving size: 1/2 cup chopped) 2-3 servings of protein daily? (eggs, raw nuts, legumes, beans, lean meats) 2 servings of calcium containing foods daily? (low-fat milk, cottage cheese, yogurt) Are you involved in an aerobic exercise program? (01234567 days/week, 0306090120 mins/session) Are you involved in a strength-training program? ( 01234567 days/week, 0306090120 mins/session)