1 How old are you?
18-24 25-34 35-45 45 or order
2 Do you feel tired often?
Always Never During the day Only at night
3 Do you eat at least 5-7 servings of “fruits and vegetables” daily?
Yes No
4 How many times a day do you move your bowels?
1 2 3 or more
5 How often do you drink tap water?
Never 1 time a day 2 to 3 times a day All day long
