It's Your Final Countdown !!

P e r s o n a l

Gender

-select- Male Female

Date of Birth

Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Months January February March April May June July August September October November December Years 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

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L i f e S t y l e

Place of birth / life spent more than 75%

-- Select -- America Asia Europe Australia Africa

What is your Tobacco exposure?

-- Select -- Never Second Hand Smoke Very Rarely Often Very Often

How often do you consume alcohol?

-- Select --NeverSome TimesOftenVery OftenUntil Intoxicated

Do you engage in unprotected sex with different partners?

-- Select --NeverVery RarelySome TimesOftenVery Often

Do you share needles during drug usage?

-- Select --I say No to DrugsVery RarelySome TimesOftenVery Often

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H e a l t h

How often do you Brush/Floss your Teeth?

-- Select --Three times a dayTwice a dayOnce a dayEvery two daysRarely

How much time do you spend in the Sun?

-- Select --NoneVery LittleModerate AmountsQuite a lotAll of the time

How often do you Exercise?

-- Select --NeverOnce a weekTwice a weekThree times a weekFour times a week

Are you over your Physicians' Recommended Weight?

-- Select --Under WeightOptimal WeightOver 15 lbsOver 30 lbsOver 50 lbs

Did you undergo any major Medical treatment/ Surgery in the last one year ? (mesothelioma / cancer / kidney / liver / bypass, blood pressure, Heart / Cardiac, diabetes, Hepatitis)

-- Select --YesNo

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D i e t

1

How often do you eat Processed Meat, Poultry?

-- Select -- Never Very Rarely Dont Eat Often Very Often

How often do you use Butter and Cream?

-- Select --NeverVery RarelySome TimesOftenVery Often

When you eat Fish, Poultry and Meat, how is it cooked?

-- Select -- Well Done Medium Well Dont Eat / Medium Medium Rare Rare

What percentage of your Diet is Non-vegetarian food?

-- Select --100%75%50%25%0%

How much Coffee do you drink a day?

-- Select --None1 Cup2 Cups3 Cups4 Cups & above

Do you take Aspirin once a day?

-- Select -- Yes No

How often do you eat Fruits and Vegetables?

-- Select --NeverVery RarelySome TimesOftenVery Often

Do you take a Multi-Vitamin once a day?

-- Select --YesNo

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Environment

Are you exposed to Air Pollution?

-- Select --YesNo

Are you in a High risk area for Radon Exposure?

-- Select --YesNo

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F a m i l y

Does Diabetes run in your immediate family?

-- Select --YesNo

If deceased, how long did your Grandparents live?

-- Select --Still AliveBefore 60Past 60Past 70Past 80Past 90

Do you frequently use 2 wheeler (or) 4 wheeler ?

-- Select -- Yes No

How often do you find yourself stressed ?	-- Select -- Some Times Veryrarely OftenVery Often
Who you are?	--select-- NormalPessimisticSadisticOptimistic
Note: This is just for entertainment and we are strongly against anyone taking serious actions based on this result - date of death.