My Wellness Survey

Form
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/fatigueAnxietyBrain fogTrouble 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 glowNone 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
I want to help you in any way i can! How can i best follow up?! Check all that apply

Product recs for your skin or overall wellnessSend me samples of things that might help!Add me to your VIP group so i can access info on these topics
What areas of your life would you want to improve? Check all that apply

Overall wellnessMore community/friendshipsMore income/financial stabilityMindset/Mental health
Are you open to hopping on a quick 15 minute consultation call to discuss your survey?

Yes!Not right now
Would you like to be added to my monthly newsletter where I send health tips and tricks, recipes, and more!

Yes pleaseNo thank you
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