Wellness/Immune Survey

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Name

First NameLast Name
Email
example@example.com
IG handle
Phone Number
Please enter a valid phone number.
Are you currently experiencing any of the following? Check all that apply.

BloatingDigestive issuesLow energy/fatigueAutoimmune disordersAnxietyBrain fogFertility issuesTrouble sleepingNone of the above
Are you currently satisfied with your skin?

YesNoCould be better
Are you experiencing any of these common skin issues? Check all that apply.

AcneOily skinDry skinSigns of agingFine lines/wrinklesDark spots/Age spotsDull skin/lacking glowEczemaRosaceaNone of the above
Are you familiar with ingredients in wellness and beauty products and how these things can affect your overall health?

I’m familiar but don’t really careI’m somewhat familiar but could use some more infoI’m an avid label reader and all about that low-tox lifeI’m not familiar with how ingredients affect my overall health
Are you familiar with gut health and how this can affect your overall health, your skin, and your mental health?

I’m familiar but could use more infoYes! I’m a gut health enthusiastNo
What is the best way for us to chat?

TextCallEmailDM - Instagram
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