1. During your lifetime have you smoked more than 100 cigarettes?
Yes
No

2. Do you smoke now?
Yes
No

3. Do you usually drink coffee (not decaf) each day?
Yes
No

4. Do you drink more than 4 cups of regular coffee each day?
Yes
No

5. In your entire life have you had at least 12 drinks of any kind of alcoholic beverage?
Yes
No

6. Women's weights change during their adult lives. Mark one answer that best describes you during your adult life. Please don't include times that you were pregnant or sick. (Select only one)

Choose Weight has stayed the same Steady gain in weight Lost weight as an adult and kept it off Weight has gone up and down by more than 10 lbs.

7. Think about the walking you do outside your home. How often do you walk outside the home for more than 10 minutes without stopping? (Select only one)

Choose 1-2 times each month 1 time each week 2-3 times each week 4 or more times each week

8a. Strenuous or very hard exercise (You work up a sweat and your heart beats fast.) For example, aerobics, aerobic dance, jogging, tennis, swimming laps.

Choose 1 day per week 2 days per week 3 days per week 4 or more days per week

8b. Moderate exercise (not exhausting). For example, biking outdoors, using an exercise machine, calisthenics, easy swimming, popular music, or folk dancing.

Choose 1 day per week 2 days per week 3 days per week 4 or more days per week

8c. Mild exercise. For example, slow dancing, bowling, or golf.

Choose 1 day per week 2 days per week 3 days per week 4 or more days per week

Thank you!