Getting to Know You First Name Last Name Age Gender - Select -MaleFemaleOthersEmail Marital Status Single Married CohabitatingWith whom do you live? (check all that apply) Self Spouse Children Parents Other relatives Other non-relativesOccupation Retired? Yes NoDo you drink alcohol? Yes NoDo you smoke? Yes NoReadiness to ChangeAre you looking to change a specific behavior? Yes NoAre you willing to make this behavioral change a top priority? Yes NoHave you tried to change this behavior before? Yes NoDo you believe there are inherent risks/dangers associated with not making this behavioral change? Yes NoAre you committed to making this change, even though it may prove challenging? Yes NoDo you have support for making this change from friends, family, and loved ones? Yes NoAre you committed to making this change, even though it may prove challenging? Yes NoBesides health reasons, do you have other reasons for wanting to change this behavior? Yes NoAre you prepared to be patient with yourself if you encounter obstacles, barriers, and/or setbacks? Yes NoPlease share any other information regarding your health and goals. Submit Form