Wellness Survey
Jennifer Gates
Name
First Name
Last 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.
Bloating
Digestive Issues
Low Energy/Fatigue
Anxiety
Brain Fog
Trouble Sleeping
Skin issues
Weight loss
Weight gain
Blood sugar balance
None of the Above
Are you currently satisfied with the look/ feel of your skin?
Yes
No
Could Be Better
Are you experiencing any of these common skin issues? Check all that apply.
Acne
Oily Skin
Dry Skin
Signs of Aging
Fine lines/Wrinkles
Dark spots/Age spots/ Post Acne Scars
Dull skin/ Uneven Skin Tone
2 or More of These Areas
None of The Above
Are you familiar with ingredients in wellness and beauty products and how they can affect your overall health?
I’m familiar, but haven't thought about looking into it
I’m somewhat familiar, but could use some more info
I’m an avid label reader and into low-tox living
I’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 info
Yes! I’m a gut health enthusiast
No
I want to help you! How can I best follow up?! Check all that apply
Product recommendations for your overall wellness
Send me samples of products that could help!
Let's chat about what products would be right for me!
What areas of your life would you want to improve? Check all that apply!
Overall Wellness
More Community/Friendships
Extra Income/Financial Stability
Mindset/Mental health
Submit
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