Q 1. What is your age? Were you born premature or with any health conditions? 2. What was your birth weight? What is your current height and weight? 3. What is your ethnic background? 4. Which city and which neighborhood did you grow up in? 5. How many schools have you attended and why? 6. Who lived in the home with you where you were raised? 7. What is your parent’s education level? 8. How would you classify your relationship with your parents? a. Great/Healthy b. Neutral c. Not Good/Unhealthy/Dysfunctional 9. What was the income range of the person/people who raised you? a. $0-$20,000/year b. $20,000-40,000/year c. $40,000-60,000/year d. $60,000-80,000/year e. More than $80,000/year 10. Have you ever been abused (sexually, physically, or emotionally)? 11. What challenges have you had to overcome in your life? How do you think these challenges have impacted you? 12. What physical disabilities do you have? 13. What mental health conditions have you been diagnosed with or feel you may have? 14. What grades did you earn in grades K-12? 15. Which extracurricular activities did you participate in? 16. What is your highest level of education? 17. List each job you have had and how long you worked there. 18. What religion were you raised in? What is your religion now? 19. Which of the following illnesses or diseases run in your family: a. Diabetes b. Heart Disease c. High Blood Pressure d. High Cholesterol e. Mental Illness (depression, anxiety, eating disorders, bipolar, ADHD, schizophrenia, addiction and substance abuse, PTSD, insomnia, other) f. Cancer 20. How often do you socialize with friends each month? 21. Describe your diet and exercise throughout your life: a. Birth to age 18 i. Healthy (range of fruits, vegetables, protein, dairy, and carbohydrates) ii. Neutral (some fruits, vegetables, protein, dairy, and carbohydrates, but some junk food and fast food) iii. Unhealthy (too many calories or not enough calories, low levels of fruit, vegetables, protein, dairy, carbohydrates, high levels of junk food and fast food) 22. How would you describe your personality? (i.e. optimistic/pessimistic, angry/happy, easy-going/high strung, etc.) 23. Were you exposed to asbestos, lead paint, second-hand smoke, or poor water quality growing up? 24. Did you go to annual medical, dental, and vision appointments growing up? When were your last appointments for these? 25. Have you experienced or witnessed domestic violence? 26. How many and which languages were spoken in your home growing up? 27. Did your parents read to you as a child? What was your access to books and toys? 28. Did your parents drink alcohol or use drugs while you were growing up? 29. Did your mother drink or use drugs while pregnant with you? 30. Were you ever neglected or abandoned?