Empowered Wellness Audit

Excited to Get to Know YOU Better!

Completing this form will allow us to empower you toward a more healthful life!
Name*

First NameLast Name
Email*
example@example.com
Best Phone to Reach you Regarding Your Answers*
Please enter a valid phone number.Format: (000) 000-0000.
What is your PRIMARY health goal?*

Regulate appetite and reduce cravingsGut healthBalance hormonesManage stress levels, daily anxiousness and overwhelm/better moodMore energyIncreased mobility, less painOther
What stands in your way from achieving your goal?*

DietStressGiving up too soonWorking outHormones/energyPainOther
How high are your stress levels?*

no worries-----------------------------------------------------------stressed out
How many hours are you sleeping at night

Less than 45-67-8Takes me hours to fall asleepI toss and turn or am awake up at night
Do you have trouble staying hydrated?

No, I drink tons of waterSometimes, I should probably drink moreAlways, constant struggle
Have you ever tried CBD?
Have you ever tried Mushrooms for wellness?
Are you taking any medications for:

Diabetes/weight lossThyroidBlood PressureMoodHigh CholesterolBlood thinners/AnticoagulantsNo MedsOther
Indicate the TOP health item you would like to seek support on and the average number of YEARS you have struggled with the issue.
ex. poor sleep, 25 years,,, or pain left leg, 10 years
Please use this space to share details or expand on any answers regarding your health, CBD or mushroom experience, or any PET issues (YES WE SERVICE PETS AS WELL).
Your Age (or the age of the person of inquiry)*

12 or under12-1718-2526-3536-4546-5556-6566-7576 or over
How did you connect with us? USE DROPDOWN*
If Referred, by who?
How ready are you to up level your health and wellness?

I have never been more ready!I want to but know I need supportI am scared, not sure if I am ready just yet
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Excited to Get to Know YOU Better!