Health Questionnaire

Health Questionnaire

Hey there,

I'm excited to see how I can help you with your health goals.

Fill in this short questionnaire and I'll be in touch with your FREE list of tips, products, services, etc. that you can consider to address your health concerns.

So, let's get started.
I get the right amount of sleep each night. *

Yes Somewhat No
I drink enough water each day. *

Yes Somewhat No
I eat the right AMOUNT of fruits and vegetables each day. *

Yes Somewhat No
I eat the right VARIETY of fruits and vegetables each day. *

Yes Somewhat No
I'm happy with the condition of my skin, nails, and hair. *

Yes Somewhat No
I'm happy with my current weight. *

Yes Somewhat No
I'm able to move around well without joint pain. *

Yes Somewhat No
I'm happy with my cardiovascular numbers (blood pressure, cholesterol). *

Yes Somewhat No
I'm happy with my energy level throughout the day. *

Yes Somewhat No
I have good gut health (no bloating, regular bowel movements, etc.). *

Yes Somewhat No
Are there any other health conditions that you’d like to share? If you answered "No" or "Somewhat" to any of the items above, feel free to elaborate so that we can provide specific advice.
Thank you for this information. It will be kept confidential.

Your report will be delivered via a text message and email. Please provide accureate information below.
Name *

First Name Last Name
Email *
example@example.com
Phone Number *

Area Code Phone Number
Should be Empty:

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