Tailored Tips for Healthier You

Name *

First Name

Last Name

Which, if any of the following symptoms are you currently experiencing?

Select all that apply

Hot flushes

Night sweats

Sleep issues

Tingling sensation

Weight gain

Loss of libido

Joint pain

Itchy skin

Memory lapses

Mood swings

Brain fog

Other

How would you describe your current diet?

Select all that apply

Plant based (vegetarian, vegan)

High protein, including meat and diary

High in process foods and sugar

Low carb/keto

Mediterranean, rich in plant foods, lean protein and olive oil

Balanced, with variety of foods from all food groups

Other

Describe your current exercise routine

Circle the ONE that applies

Sedentary Lifestyle I rarely or never exercise.

Light exercise such as waling or yoga 1-2 times per week

Moderate Exercise Like cycling, swimming, or brisk walking 3-4 times per week.

Active Lifestyle Activities such as running, aerobics, or heavy lifting at least 5 times a week.

Varied Routine Mix of different activities and intensity levels throughout the week.

What practices do you currently engage in for your mental health?

Select the ONE that applies

Mindfulness/Meditation

Social activites

None, but interested

None, but not interested