Will You Live To Be 100? – Woman's Worth

Are you male or female?

Male
Female

Do you smoke or chew tobacco, or are you around a lot of secondhand smoke?

Yes
No

Do you cook your fish, poultry or meat until it is charred?

Yes
No

Do you avoid butter, cream, pastries and other saturated fats as well as fried foods (e.g. French Fries)?

Yes
No

Do you minimize meat in your diet, preferably making a point to eat plenty of fruits, vegetables, and bran?

Yes
No

Do you consume more than two drinks of beer, wine and/or liquor a day?

A standard drink is one 12 oz. bottle of beer, one wine cooler, one 5 oz. glass of wine, or one and a half oz. of 80 proof distilled spirits.

Yes
No

Do you drink beer, wine, and/or liquor in moderate amounts (one or two drinks/day)?

Yes
No

Do air pollution warnings occur where you live?

Yes
No

Do you drink more than 16 ounces of coffee a day?

Yes
No

Do you drink tea daily?

Yes
No

Do you take an aspirin a day?

Yes
No

Do you floss your teeth every day?

Yes
No

Do you have a bowel movement less often than once every two days?

Yes
No

Have you had a stroke or heart attack?

Yes
No

Do you try to get a suntan?

Yes
No

Are you more than 20 pounds overweight?

Yes
No

Do you live near enough to family members (other than your spouse and dependent children) that you can and want to drop by spontaneously?

Yes
No

Which statement applies to you?

A) "Stress eats away at me. I can't seem to shake it off."
B) "I can shed stress." This might be praying, exercising, meditating, finding humor in everyday life, or other means.

Did both of your parents either die before age 75 of non-accidental causes or require daily assistance by the time they reached 75?

Yes
No
Don't Know

Did one or more of the following relatives live to at least 90 in excellent health: parents, aunts/uncles, grandparents?

Yes
No
Don't Know

Are you a couch potato (no regular aerobic or resistance exercise)?

Yes
No

Do you exercise at least three times a week?

Yes
No

Do you take vitamin E (400-800 IU) and selenium (100-200 mcg) every day?

Yes
No

Name*

First Last

Email*

Phone

This field is hidden when viewing the form

Subtotal

questions added up.

This field is hidden when viewing the form

Subtotal divided by 5

This field is hidden when viewing the form

Total

Subtotal / 5 + male or female score

Phone

This field is for validation purposes and should be left unchanged.