I. Are you physically active and exercise regularly?

1- Sedentary without regular exercise

2- Sedentary with regular exercise

3- Active without regular exercise

4- Active with regular exercise

II. How often do you eat-out, consume junk food and fast-food?

1- Everyday (all meals)

2- Everyday (1 meal)

3- Alternate days

4- Twice a week

5- Once a week

6- Once a month

III. Do you have any hereditary conditions/diseases?

1-High blood pressure

2- Diabetes

3-Hemophilia

4- Thalassemia

5- Huntington

6- Other (Please specify can be picked for other or none)

IV. How often do you get a health checkup?

1- Once in 3 months

2- Once in 6 months

3- Once a year

4- Only when needed

5- Never get it done

 V. Has a lack of health insurance coverage made you consider one of the following?

1- Skip a doctor’s appointment

2- Cancel an appointment with the doctor

3- Postpone a doctors appointment

4- Not purchase medicine

5- Delay treatment