Sex |
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Date of Birth |
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If you live in the United States, please enter your zip code. If outside the US, enter your
country:
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Within the last 7 days, how many days have you done each of the
following:
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1. Exercised strenuously |
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2. Had difficulty sleeping |
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3. Eaten junk or other kind of fast food |
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4. Had a heart to heart talk with a friend |
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5. Attended a meeting or other organized social event |
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6. Received a ticket, citation, or warning from a police or other authority |
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7. Wrote down your thoughts or feelings |
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8. Drank alcohol |
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9. Smoked at least one cigarrette or other tobacco product |
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10. Took medication prescribed by a physician for a health problem |
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11. Took medicine not prescribed by a physician (e.g., aspirin, cough medicine) |
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12. Activity was restricted in some way because of illness or poor health |
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