Please fill out the below to the best of your ability / knowledge.

Name *
Name
What is the best phone number to reach you? *
What is the best phone number to reach you?
Date of Birth *
Date of Birth
Heart disease, high blood pressure, cancer, surgeries, etc.
Current Lifestyle Choices *
Please check all that apply
Current Diet / Food Choices *
Please check all that apply.
Please list breakfast, lunch, dinner, and snacks
Sweets? Salty? Fried?
1 serving = 1 cup
If yes, please describe.
Do you want your name made public as part of The Way VI Team? *
Type AGREE here.