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  1. How much sleep do you get each night?
    • At least seven hours
    • Less than seven hours
  2. Do you smoke?
    • Yes
    • No
  3. Do you drink more than three drinks a week?
    • No
    • Yes
  4. Do you get at least a half hour of exercise, six days a week?
    • No
    • Yes
  5. Do you take a multivitamin regularly?
    • No
    • Yes
  6. Are you overweight?
    • Yes
    • No
  7. Do you floss your teeth daily?
    • Yes
    • No
  8. Do you like to drive fast?
    • No
    • Yes
  9. Have you driven drunk (or ridden with a drunk driver) in the past three years?
    • Yes
    • No
  10. Your relationship status is:
    • In a happy committed relationship
    • Single or in an unhappy relationship
  11. Do you eat your fruits and vegetables?
    • Not really
    • Yes
  12. Do you eat breakfast?
    • Daily
    • Now and then
  13. Do you suffer from depression?
    • No
    • Yes
  14. Do you practice safe sex?
    • Not every time
    • Always
  15. In general, you'd say your life is:
    • Stressful
    • Pretty low stress
  16. Do you belong to a volunteer group or church you attend regularly?
    • Yes
    • No
  17. You consider yourself to be:
    • Lucky
    • Unlucky
  18. Do you own a dog?
    • No
    • Yes
  19. Do you practice meditation or yoga?
    • Yes
    • No
  20. Your household income is:
    • On the low side
    • On the average to high side

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