HABITS:
Adequate exercise .
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Sleep well...
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Bowels move regularly .
Diet well balanced. ....
Fruit servings per day
..
Vegetables per day.
Eogs per day. . ... ae
Bread, slices per day .
Potato servings per day .
Cereal servings per day. .
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Meat servings per day.
NOTE: Diet
for an
average day.
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Milk, glasses per day .
Coffee, cups per day
Tea, cups/glasses per day .
Soft drinks per day .
Water, glasses per day
Salt used _little
.
moderate “much
.
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.
Spices, pepper, pickTes, etc
much
moderate
little
Alccholic beverages
none __rarely __moderatelydaily
Tobacco:
Cigarettes, pks per “ay
Cigars .. . 2...
Pipe ..
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Drugs:
Laxatives .. . 2 « s
Vitamins
Sedatives ...
‘
Tranquilizers ...
sleeping pills...
Aspirin.
.
Cortisone, Acth .
Thyroid...
se as
‘Appetite depressants.
Treatment for drug habits .
Insulin. ...
os
Tablets for diabetes.
Hormone shots or tablets.
Other (please specify). . .
Work:
Hours per day
=
8
4 or less
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4 or more
Indoors
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9 or more