Dirk Struik - Age 104 MICHAEL LUTCH

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MALE FEMALE
AGE
1. Do you smoke or chew tobacco, or are you around a lot of secondhand smoke?
YES NO
2. Do you eat more than a couple of hot dogs, slices of bacon, or a bologna sandwich a week?
YES NO
3. Do you cook your fish, poultry, or meat until it is charred?
YES NO
4. Do you avoid butter, cream, sweets and other saturated fats as well as fried food (e.g. French Fries)
YES NO
5. Do you minimize meat in your diet, preferably making a point to eat plenty of fruits, vegetables and bran instead?
YES NO
6. Do you drink beer, wine and/or liquor in excess (more than two drinks*/day)?
(*A standard drink is: one 12-ounce bottle of beer, or wine cooler, one 5-ounce glass of wine, or 1.5 ounces of 80-proof distilled spirits)
YES NO
7. Do you drink beer, wine and/or liquor in moderate amounts (1-2 drinks*/day)?
(*A standard drink is: one 12-ounce bottle of beer, or wine cooler, one 5-ounce glass of wine, or 1.5 ounces of 80-proof distilled spirits)
YES NO
8. Do air pollution warnings occur where you live?
YES NO
9. A. Do you drink more than 16 ounces of coffee a day?
YES NO
B. Do you drink green tea daily instead?
YES NO
10. Do you take an aspirin a day?
YES NO
11. Do you floss your teeth every day?
YES NO
12. Do you have a bowel movement less than once every two days?
YES NO
13. Do you engage in risky sexual (unprotected or promiscuous) or drug-related behavior that increase your risk of contracting HIV or viruses that can cause cancer?
YES NO
14. Do you try to get a suntan?
YES NO
15. Are there dangerous levels of radon in your house?
YES NO
16. I weigh lbs. and my height is feet, inches
17. Do you live near enough to other family members (other than your spouse and dependent children) that you can drop by spontaneously?
YES NO
18. Which statement is applicable to you?
A. "Stress eats away at me. I can't seem to shake it off."
YES NO
B. "I can shed stress." This might be by praying, exercising, meditation, being able to respond to humor or by other means.
YES NO
19. Does more than one member of your immediate family (parents and siblings) have diabetes?
YES NO
20. A. Did both your parents die before age 75 years of non-accidental causes?
YES NO
B. Or, did they both (or one of them if the other died before age 75) require daily assistance by the time they reached age 75?
YES NO
21. Did more than one of the following relatives in your family live to at least age 90 years in excellent health: parents, aunts/uncles, or grandparents?
YES NO
22. A. Are you a couch potato (no regular aerobic or resistance exercise)?
YES NO
B. Do you exercise 20 minutes a day or more?
YES NO
23. Do you take vitamin E (800IU) and selenium (100-200 mcgm)
everyday?
YES NO