-
EXCELLENT
VERY GOOD
GOOD
FAIR
POOR
DON'T KNOW
-
DON'T KNOW
NO
YES
:
cm
in
:
:
:
:
kgs
lbs
:
:
CHRONIC BRONCHITIS OR EMPHYSEMA
CANCER
DIABETES
HEART DISEASE
DON'T KNOW
PREFER NOT TO ANSWER
NO
AUTISM
ATTENTION DEFICIT DISORDER
ANXIETY DISORDERS SUCH AS PHOBIA
ALLERGIES
AMYOTROPHIC LATERAL SCLEROSIS (ALS, LOU GEHRIG'S DISEASE)
ALZHEIMER'S DISEASE OR DEMENTIA
ARTHRITIS OR RHEUMATISM
ALCOHOLISM/SUBSTANCE ABUSE/ADDICTION (OF ANY KIND INCLUDING GAMBLING)
ASTHMA
BACK PROBLEMS
BULIMIA
CATARACTS
CROHN'S DISEASE OR COLITIS
CELIAC DISEASE
CEREBRAL PALSY
CHRONIC FATIGUE SYNDROME
CYSTIC FIBROSIS
DEVELOPMENTAL DISORDERS
DEPRESSION
DOWN SYNDROME
EATING DISORDERS SUCH AS ANOREXIA NERVOSA
EPILEPSY
FOOD ALLERGIES
HIGH BLOOD PRESSURE
HEMOPHILIA
HIV / AIDS
HYPOGLYCEMIA
MULTIPLE CHEMICAL SENSITIVITIES
MUSCULAR DYSTROPHY
MOOD DISORDERS SUCH AS BIPOLAR DISORDER OR MANIC DEPRESSION
MIGRAINE
MULTIPLE SCLEROSIS (MS)
PARKINSON'S DISEASE
SCHIZOPHRENIA
STOMACH/INTESTINAL ULCERS
SLEEP APNEA
SPINA BIFIDA
STROKE
THYROID PROBLEMS
URINARY INCONTINENCE
DON'T KNOW
PREFER NOT TO ANSWER
NO
AUTISM
ATTENTION DEFICIT DISORDER
ANXIETY DISORDERS SUCH AS PHOBIA
ALLERGIES
AMYOTROPHIC LATERAL SCLEROSIS (ALS, LOU GEHRIG'S DISEASE)
ALZHEIMER'S DISEASE OR DEMENTIA
ARTHRITIS OR RHEUMATISM
ALCOHOLISM/SUBSTANCE ABUSE/ADDICTION (OF ANY KIND INCLUDING GAMBLING)
ASTHMA
BACK PROBLEMS
BULIMIA
CATARACTS
CROHN'S DISEASE OR COLITIS
CELIAC DISEASE
CEREBRAL PALSY
CHRONIC FATIGUE SYNDROME
CYSTIC FIBROSIS
DEVELOPMENTAL DISORDERS
DEPRESSION
DOWN SYNDROME
EATING DISORDERS SUCH AS ANOREXIA NERVOSA
EPILEPSY
FOOD ALLERGIES
HIGH BLOOD PRESSURE
HEMOPHILIA
HIV / AIDS
HYPOGLYCEMIA
MULTIPLE CHEMICAL SENSITIVITIES
MUSCULAR DYSTROPHY
MOOD DISORDERS SUCH AS BIPOLAR DISORDER OR MANIC DEPRESSION
MIGRAINE
MULTIPLE SCLEROSIS (MS)
PARKINSON'S DISEASE
SCHIZOPHRENIA
STOMACH/INTESTINAL ULCERS
SLEEP APNEA
SPINA BIFIDA
STROKE
THYROID PROBLEMS
URINARY INCONTINENCE
DON'T KNOW
PREFER NOT TO ANSWER
NO
IN OTHER ACTIVITIES SUCH AS TRANSPORTATION TO OR FROM WORK OR LEISURE TIME ACTIVITIES.
AT HOME
AT WORK OR AT SCHOOL
DON'T KNOW
PREFER NOT TO ANSWER
NO
-
EXCELLENT
VERY GOOD
GOOD
FAIR
POOR
DON'T KNOW