Health & Wellness Survey
Empowered Living Nutrition
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
What do you consider your biggest health and weight loss challenge right now? Choose all that apply.
*
Loosing Weight
Mood Swings
Anxiety
Brain Fog
Low Energy
Sugar Addiction
Time Management
Cant stay focused/Scattered attention
Endless cravings
Insomnia
Emotional Eating
Digestive Issues
Other
What do you feel is the biggest obstacle holding you back from overcoming your pain points? Choose all that apply.
Time
No support from friends or family
Too much conflicting information out there and I don't know where to begin
Tried before and failed so afraid to attempt again
Don't know what to eat or cook, need recipes
Don't know what to do, hard to implement into daily routine
Burned Out, Overwhelmed
Other
What are your favorite ways to learn when it comes to your health & wellness? Check all that apply.
Written text(PDF's, books, manuals, ect)
Video
Audio
Group Coaching
One on One Coaching
Virtual Webinars
Live in person workshops or Events
Facebook Groups
Other
What are you interested in learning? Check all that apply.
How to build your immune system?
How to quit sugar
How to plan healthier meals/recipes/shopping lists
How to have a happy healthy gut
How to improve your 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 eat healthy on a budget
How to make healthier meals the whole family will enjoy
Tips for kids wellness and kid friendly recipes
Time saving healthy tips for busy people
How to go gluten free
Other
What is your biggest frustration when it comes to your health & wellness goals? I want to know. If you chose other above you can also elaborate on those in this section.
Submit
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