What is your age chronologically? How "old" do you feel?

Please check one:

male
female

Do you consider your life stressful?

yes
no

Please comment:

Do you meditate?

yes
no

What types of activities do you do to relax, balance and center?

Do you enjoy reading? If so, what type of books do you enjoy?

Do you schedule time for play?

Are you a member of a spiritual community?

Do you exercise? What do you do?

Do you like to dance?

Do you spend time with your family playing?

Do you have talk nights with your family?

Have you ever been told you were seriously ill?

Have you ever taken any classes on healing?
If so, which ones?

Have you ever had a miracle healing?

Do you have any interesting healing stories to share about others?

What do you eat and how often?

Do you feel you are overweight?

Would you like to reduce your body fat?

Do you have energy level swings throughout the day?

Do you smoke?

yes

no

Do you have a family history of stroke or heart attack? Which one?
Or any other things in family history?

Do you suffer from any joint discomfort?

Are you taking any nutritional supplements?

Is there any particular type of vitamins or supplments
you recommend to friends?

Are you susceptible to colds and or flu?

Are strong bones important to you?

Do you have concerns with short-term memory loss or an inability to concentrate?

Are you concerned with premature aging?

What do you think makes for a healthy life?


Anything else you'd like to say?

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