Tobacco Use:

(If you never use tobacco enter a score of 10 for this section and go to the next section)

| | |Almost Always |Sometimes |Never |
|1 |I avoid smoking tobacco. |2 |1 |0 |
|2 |I avoid using a pipe or cigars. |2 |1 |0 |
|3 |I avoid spit tobacco. |2 |1 |0 |
|4 |I limit my exposure to environmental tobacco smoke |2 |1 |0 |
| | | |Total: |10 |

Alcohol and Other Drugs:

| | |Almost Always |Sometimes |Never |
|1 |I avoid alcohol or I drink no more than 1 (women) or 2 (men) drinks a day. |{4} |1 |0 |
|2 |I avoid using alcohol or other drugs as a way of handling stressful situations or |{2} |1 |0 |
| |problems in my life. | | | |
|3 |I am careful not to drink alcohol when taking medications, such as for colds or |{2} |1 |0 |
| |allergies, or when pregnant | | | |
|4 |I read and follow the label directions when using prescribed and over-the-counter |{2} |1 |0 |
| |drugs | | | |
| | | |Total: |10 |

Nutrition:

| | |Almost Always |Sometimes |Never |
|1 |I eat a variety of foods each day, including seven or more servings of fruits and |3 |{1} |0 |
| |vegetables. | | | |
|2 |I limit the amount of total fat and saturated and trans fat in my diet. |{3} |1 |0 |
|3 |I avoid skipping meals |{2} |1 |0 |
|4 |I limit the amount of salt and added sugar I eat |2 |{1} |0 |
| | | |Total: |7 |

Exercise/Fitness:

| | |Almost Always |Sometimes |Never |
|1 |I engage in moderate exercise for 20-60 minutes, 3-5 times a week |4 |{1} |0 |
|2 |I maintain a healthy weight, avoiding overweight and underweight |2 |1 |{0} |
|3 |I do exercises to develop muscular strength and endurance at least twice a week |2 |{1} |0 |
|4 |I spend some of my