Questionnaire – Epigenetic Test

Your contact details

Name*
First name*
Date of birth (DD/MM/YYYY)*

Gender* MaleFemale

Consumption of fruits and vegetables

1. Fruits - frequency

On average, how many days a week do you eat fruits or drink fruit juice?

Indicate the number of days per week (one digit between 0 and 7).

2. Fruits - amount

On those days, how many servings of fruit or fruit juice do you eat/drink on average? One serving is about the size of a fist, or on apple, pear, etc. For fruit juice, one portion corresponds to about 2 dl.

Indicate the number of portions per day (one number between 0 and 20).

3. Vegetables - frequency

Usually, how many days a week do you eat vegetables or salads or drink vegetable juices ? Not counting potatoes.

Indicate the number of days per week (one digit between 0 and 7).

4. Vegetables - amount

On those days, how many servings of vegetables, salad or vegetable juice do you eat on average?
One portion is about the size of a fist, or a tomato, a large carrot, etc. For vegetable juice, one portion is about 2 dl.

Indicate the number of servings per day (a number between 0 and 20).

Consumption of tobacco and similar products

5. Actual tobacco

Do you currently smoke? « Yes » means a minimum of 1 cigarette/cigarillos/heated tobacco product/ e-cigarette per day or 1 cigar/pipe/shisha/marijuana per week for one year.

Yes, I smokeNo, I do not smoke

6. Actual tobacco: frequency and amount

If you smoke, please specify which product you currently smoke, for how long and in what quantity.

7. Past tobacco

Have you ever smoked in the past? « Yes » means a minimum of 1 cigarette/ cigarillos/ heated tobacco product/ e-cigarette per day or 1 cigar/pipe/shisha/marijuana per week for one year.

Please answer this question if your current consumption has changed from your past consumption.

Yes, I smoked in the pastNo, I never smoked

If the answer is “yes”, go to question 8; if not, go directly to question 9.

8. Past tobacco: frequency & amount

If you have smoked in the past, please specify which product you smoked, for how long and in what quantity.

9. Past tobacco

How many years ago did you quit smoking?
Please specify in number of years; If you quit less than a year ago, score 1.

Year(s)

I do not know

Alcohol consumption

10. Alcohol - frequency

Usually, how many days a week do you consume one or more alcoholic beverages?

Indicate the number of days per week (one digit between 0 and 7).

11. Alcohol - amount

When you consume an alcoholic beverage, how many drinks do you usually take?
A standard drink corresponds to about 3 dL of beer (5% vol.), 1 dL of wine (12.5% vol.), 4 cL of liqueur (30% vol.), 2 cL of strong alcohol (55% vol.).

Indicate the number of drink(s) per day:

Physical activity

12. Moderate physical activity

During a typical week, how often do you engage in moderate physical activity (causing mild shortness of breath) such as dancing, gardening, fast walking, etc.?

Indicate the number of days per week (one digit between 0 and 7).

On these days, on average, how long are you active?
Minutes / day:

13. Intense physical activity

During a typical week, how often do you engage in intense physical activity during which you are out of breath or sweating?

Indicate the number of days per week (one digit between 0 and 7).

On these days, on average, how long are you intensively active?
Minutes / day: