Age: Height: Weight:*
What name do you like to go by?Name
Do you smoke Yes No*
How often do you drink? Rarely Weekends only Daily Never*
Do you practice yoga? Often Rarely Not at all
Can you walk a mile without stopping? Yes No
Do you meditate? Sometimes Rarely Daily Not at all
Check your top three health concerns:Aging more slowlyy Managing my weight Reducing Anxiety Energy Balance g