Daily Life Style Survey

Do you think breakfast is important?

What do you usually take for your breakfast?

Do you skip breakfast sometimes?

No, I never skip.

Yes, sometimes I do.

Do you think that exercise is important?

What kind of exercise you are doing?

How many times you exercise in a week?

1-2 times per week

3-4 times per week

5-7 times per week

Have you done any medical check up or blood test this year?

Yes

No

Do you have the following concerns?

Contact Information

* First Name :

* Last Name :

Address 1 :

Address 2 :

City :

State :

Zip :

* Phone :

* Email Address :

Daily Lifestyle Survey