Health & Wellness Survey
Full Name
First Name
Last Name
E-mail
*
Preferred method of contact
*
Email
Instagram message
Text message
Phone Number
-
Area Code
Phone Number
Instagram Handle
1. What do you consider your biggest health and wellness challenge is right now? Choose all that apply.
*
Chronic Pain
Low Energy
Mood Swings
Anxiety
Losing Weight
Can't Focus, Scattered Attention
Sugar Addiction
Endless Cravings
Digestive Issues
Insomnia
Emotional Eating
Brain Fog
Low Immune system
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
Too much conflicting information out there and 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
Know what to do, but hard to implement into daily routine
Other
3. What is your biggest frustration or fear when it comes to your health and wellness goals? I want to know! If you chose “other” in the answers above, you can also elaborate on those in this section.
*
Submit
Should be Empty: