Here; you can mail it.
1. Age: 40
2. Gender: male
3. Do you work? yes
If yes, how many hours a week do you work? 60/week during the school year.
4. How many hours per week do you spend commuting to appointments, school, work, other responsibilities? Roughly 1 hour per week.
5. Do you attend school? I'm a teacher; they make me go if I want to get paid.

If yes, how many hours a week do you spend at school? roughly 50 hours per week
6. Do you smoke cigarettes? Never
7. Do you suffer from anxiety or panic attacks? Nope
8. How often are you more than 10 minutes late to work or school? Never. Homeroom just wouldn't work without me.
9. How many caffeinated beverages (i.e.: coffee, tea, soda, energy drinks) do you typically drink per day? 3
10. How many hours of sleep do you average per night? varies greatly between 4 and 8.
11. How often do you exercise for a period of 20 minutes or longer (includes walking and sports)? If you'll include physical labor such as cleaning out stalls in a barn, 3-4 times/week, sometimes that 20 minutes is actually several hours.