Oxidative Stress Screening Questionnaire Form
Oxidative Stress Screening Questionnaire
How often do you experience unexplained fatigue or low energy?
*
Never
Rarely
Sometimes
Often
Almost always
How would you rate your average daily stress level?
*
1
2
3
4
5
How many servings of fruits and vegetables do you eat per day?
*
0-1 servings
2-3 servings
4-5 servings
6 or more servings
Do you smoke or use tobacco products?
*
No
Yes, occasionally
Yes, regularly
Former smoker
How many days per week do you engage in moderate physical activity (e.g., brisk walking, cycling)?
*
0 days
1-2 days
3-4 days
5-7 days
How would you describe your typical sleep quality?
*
Very poor
Poor
Average
Good
Excellent
Have you noticed increased frequency of infections or slow wound healing?
*
No
Rarely
Sometimes
Often
How often do you consume alcohol?
*
Never
Occasionally (1-3 times/month)
Regularly (1-4 times/week)
Frequently (5 or more times/week)
Are you regularly exposed to environmental pollutants (e.g., air pollution, chemicals, radiation)?
*
No
Occasionally
Frequently
Unsure
Do you have any chronic health conditions (e.g., diabetes, hypertension, autoimmune disease)?
*
No
Diabetes
Hypertension
Autoimmune disease
Other
Submit
Should be Empty: