1. In the last year, how often did you eat to excess?
5   Never
4 Once or twice
3 3 to 5 times
2 At least once a month
1 Weekly or more often
2. How is your memory?
5 It has always been excellent
4 I’m occasionally absent-minded
3 I seem to forget things more than ever, and it’s annoying
2 I definitely feel that my memory is slipping
3. How many times in the last month have you had trouble falling asleep?
5   Not at all
4 Once
3 Four or five times
2 Several times a week
1 More often than not
4. Do you have outbreaks of cold sores, shingles, or herpes?
5 No
4 Sometimes I get cold sores around my mouth
3 I have occasional outbreaks of genital herpes
2 I often have outbreaks of genital herpes and sores on my body
5. Do you have chronic aches and pains?
5 No, never
4 I have in the past, but not lately
3 Occasionally, but they are not serious
2 I frequently am bothered by pain
1 I have chronic pain that often stops me from doing things
6. Do you have trouble controlling your weight?
5 No, I have always weighed the right amount
4 I’m not overweight, but I’m always dieting
3 My weight tends to fluctuate
2 I gain weight very easily
1 No matter what I’ve tried, I can’t lose weight
7. Do you have arthritis?
5 No, never
4 Occasional or mild twinges
3 I have moderate pain, frequently
2 I have severe, chronic pain
8. How well preserved are you?
5 I have always looked younger than my age
4 I look good for my age
3 I look about average for my age
2   I’m showing my age
1   I look older than I should
9. How fast does your hair grow?
5   Very fast
4 Moderately quickly
3 Not as fast as it used to
10. Do you suffer from mood and energy swings?
5 No, never
4 I have in the past, but not now
3 Yes
11. How alert and attentive are you?
5 Very alert with good mental energy and organization
4 Usually alert
3 I catch my mind wandering often
2 I can’t think as clearly as I used to
1 I can’t seem to concentrate well any more
12. Does your job throw your body clock off balance?
5 No, I work days and have regular days off each week
4 Occasionally I work overtime or rotate shifts
3 I travel often and suffer from jet lag
2 My work schedule prevents me from sleeping regularly
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