| Have you ever had any of the following illnesses? | Hypertension/diabetes/periodontal disease/stomach or duodenal ulcer/stroke/cerebral infarction/intracranial hemorrhage/hyperlipidemia/liver disease/cancer/angina/myocardial infarction/none |
| Do you currently take any medicines? | Yes (number of medicines: …..)/No |
| What time do you get up and sleep? | Get up at about …../Sleep at about…… |
| What time do you have each meal of the day? | Breakfast at about ……./No breakfast Lunch at about ……./No lunch Dinner at about ……./No dinner Midnight snack at about ……./No midnight snack |
| How often do you eat out? (including take-out food) | Every day/Sometimes (….. times a week)/ No eating out |
| Do you pay attention to sugar intake? | Yes, very much/Sometimes/No |
| Do you pay attention to the order of eating (i.e., vegetables first)? | Yes, very much/Sometimes/No |
| How do you eat your meal every day? | Eat until full/Finish before getting full/Eat small |
| How do you drink water every day? | 1 – 2ℓ consciously/When thirsty/Rarely |
| Do you take any nutritional supplements? | Yes (number of supplements:……)/No |
| How do you sleep at night? | Sufficient/Not enough/Not at all |
| When do you go to bed? | More than 2 hours after dinner/1-2 hours after dinner/Within an hour after dinner |
| What do you think of your body type? | Fat/Thin/Standard |
| Do you think you lack exercise? | Yes/No |
| Do you feel a decrease in muscle strength? | Yes/No |
| Do you continue exercise of more than 30 minutes more than twice a week for more than a year? | Yes/Yes, but for less than a year/No such exercise |
| Do you feel stress in daily living? | Not at all/Sometimes/Yes, on a daily basis |
| Is there a lot of trouble? | Not at all/Sometimes/Yes, on a daily basis |
| Do you smoke? | Yes (….. tobaccos a day/for ….. years)/No/I used to, but I quit …...years ago |
| How many times do you drink alcohol? | Every day/….times a week/….. times a month/ Rarely/I used to, but I quit |