General - Lifestyle Environmental Questionnaire

Lifestyle & Environmental Exposures Questionnaire

Diet and Nutrition

Which of the following best describes your typical dietary pattern? * Required

Describe your typical daily meals, snack habits, and any food sensitivities: * Required

On average, how much water or hydrating fluids do you drink daily? * Required

What is your typical daily consumption of caffeine (coffee, tea, energy drinks, soda)? * Required

Physical Activity & Fitness

How often do you engage in moderate to vigorous physical activity? * Required

Please describe the types of exercise or physical activities you perform (e.g., walking, weightlifting): Optional

Stress & Wellbeing Support

Rate your average level of daily stress over the past month (1 = Low/Manageable, 10 = Overwhelming): * Required

1 2 3 4 5 6 7 8 9 10

How do you typically manage or cope with stress (e.g., meditation, hobbies, exercise, talking to friends)? Optional

Habits & Substance Use

What is your history of tobacco or nicotine use (including vaping, smoking, chewing)? * Required

If former or current user, please specify product type, amount, and duration/quit date: Optional

How often do you consume alcoholic beverages? * Required

Environmental & Workplace Exposures

Have you had any known exposure to dampness, visible mold, or water damage at home or work? * Required

Yes No

If yes, please describe the location, duration, and any symptoms associated with the exposure: Optional

Select any environmental factors you believe you are regularly exposed to: (Select all that apply) Optional

Pesticides, herbicides, or lawn chemicalsSolvents, chemical fumes, or heavy industrial dustHeavy metals (e.g., lead, mercury, arsenic)Poor indoor or outdoor air quality (e.g., smog, dust, dander)High electromagnetic field (EMF) exposureUnfiltered city tap water

How much time do you typically spend outdoors in direct sunlight per day? * Required

General - Lifestyle Environmental Questionnaire

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