Health & Wellness Survey
Full Name
*
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
*
example@example.com
1. What do you consider your biggest health and wellness challenges to be right now? Choose all that apply.
*
Losing Weight
Low Energy
Can't Focus, Scattered Attention
Sugar Addiction
Endless Cravings
Digestive Issues
Insomnia
Emotional Eating
Brain Fog
Other
2. What do you feel is the biggest obstacle holding you back from overcoming your pain points? Choose all that apply.
*
Time
Burned out, Overwhelm
No support from friends or family
No support from a wellness or health professional
Don't know where to begin
Tried before and failed so afraid to attempt it again
Don't know what to eat or cook, need recipes
Other
4. What are you interested in learning? Choose all that apply.
*
How to build your immune system
How to decrease sugar
How to plan healthier meals/recipes/shopping lists
How to have a happy healthy gut
How to improve mindset/mental wellness
How to make healthy habits stick
Virtual Fitness Programs you can do at home
How to lose weight and keep it off
How to make healthier meals the whole family will enjoy
Time-saving healthy tips for busy people
How to go Gluten Free
Other
How did you find me?
*
Kelli's Instagram
Kelli's Facebook
Kelli's TikTok
Ms. Senior World Pageants
Would you be interested in hearing how you could receive nutrition supplements, or earn supplemental income?
Yes
No
Possibly
What is your height, weight, and age? (Needed to calculate protein needs)
*
Submit
Should be Empty: