5. Do you have a dentist that you visit regularly?

6. How many times in the last six months have you been to the emergency room?

7. How many times, in the last six months, were you admitted to the hospital?

8. How often do you smoke?

9. Since when are you smoking?

10. How often do you consume alcohol?

11. Since when are you consuming alcohol?

12. How often do you chew tobacco?

13. Since when are you chewing tobacco?

14. How often do you consume any other addictive stimulant drug?

15. Since when are you consuming any other addictive stimulant drug?

16. How many servings of fruits and vegetables do you usually eat each day?

17. How many servings of fiber or whole grain foods do you usually eat each day?

18. How many servings of meat, fish, or other protein do you usually eat each day?

19. How many servings of fried or high-fat foods do you usually eat each day?

20. How many servings of sugar-sweetened drinks do you usually have each day?

21. How many days a week do you exercise?

22. On the days that you exercised, how long did you exercise?

23. How intense is your exercise?

24. Do you use alternative modes of transportation, such as stairs instead of elevator, biking or walking instead of driving, whenever possible?

25. How many hours of sleep do you usually get?

26. Do you snore or has anyone told you that you snore?

27. In the past seven days, how often have you felt sleepy during the daytime?

28. Which of the following can you do on your own without help?

29. Which of the following can you do on your own without help?

30. Many people experience leakage of urine, also called urinary incontinence. In the past six months, have you experienced leaking of urine?

31. How long can you walk or move around?

32. Which of these assistive devices do you use?

33. Do you have trouble with your balance?

34. Have you fallen in the last six months?

35. Do you have problems with vision

36. Do you use eyeglasses or contact lenses?

37. Do you have problems with hearing?

38. Do you use hearing aids or other devices to help you hear

39. In the past two weeks, how often have you felt pain?

40. Where is the pain?

41. How do you treat the pain?

42. Rate your pain on a scale of 0-10 with 0 being no pain and 10 being the worst pain: Circle the number on the scal

43. What is your living situation?

44. Does your home have working smoke alarms?

45. Do you fasten your seatbelt in vehicles?

46. Little interest or pleasure in doing things.

47. Feeling down, depressed, or hopeless.

48. Trouble falling or staying asleep or sleeping too much.

49. Feeling tired or having little energy.

50. Poor appetite or overeating

51. Feeling bad about yourself or that you’re a failure or have let yourself or your family down.

52. Trouble concentrating on things, such as reading the newspaper or watching television.

53. Moving or speaking so slowly that other people could have noticed. Or the opposite – being so fidgety or restless that you’ve been moving around a lot more than usual.

54. Thoughts that you would be better off dead or of hurting yourself.

55. If you checked off any problems in this section, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

56. Which of the following applies to you?

57. How often do you get out and meet with family and friends?

58. Do you have a health care power of attorney or a living will?

59. Would you like more information?

60. Excessive or Irregular Menstrual Periods.

61. State of Pregnancy.

62. Any Complications During Pregnancy.

63. Gynac surgery.

64. Whether on oral pills.