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Age Range
 
< 30
 
30 - 40
 
40 - 50
 
> 50
 
 
 
Weight
 
< 60
 
60 - 80
 
80 - 100
 
> 100
 
 
 
Height
 
< 165
 
165 - 175
 
175 - 190
 
> 190
 
 
 
Do you smoke ?
 
Yes
 
No
 
 
 
If Yes how frequently ?
 
< 1 pack a day
 
> 1 pack a day
 
Social smoker
 
 
 
Do you smoke cigars ?
 
Yes
 
No
 
 
 
Do you drink alcohol ?
 
Yes
 
No
 
 
 
If yes how frequently ?
 
Daily
 
With lunch/dinner
 
Weekends
 
Never
 
 
 
Do you generally eat health food ? (ex: avoid fried food)
 
Yes
 
No
 
 
 
Do you eat junk food ?
 
Yes
 
No
 
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