It's Your Time of Death !!

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

---

L i f e  S t y l e

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

---

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

---

D i e t

How often do you eat Processed Meat, Poultry?

-- Select -- Never Very Rarely Some Times 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

 

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

---

Environment

Are you exposed to Air Pollution?

-- Select --YesNo

 

What place do you live in?

-- Select -- Big city Medium city Small town Country

 

Are you in a High risk area for Radon Exposure?

-- Select --YesNo

---

F a m i l y

Does Diabetes run in your immediate family?

-- Select --YesNo

 

How old is your Grandparents?

-- Select --<6060-7070-8080-9090-100>100

 

How often do you find yourself stressed ?	-- Select -- Some Times Veryrarely OftenVery Often

© 2008 DeathGrave.com

   HomePage

   Death Grave

   Death Layouts

   Death Videos

   Submit Videos

E-mail a Friend