Health & Wellness Survey
Please answer questions below so I can help you reach your health goals.
Name
*
First Name
Last Name
Email
*
example@example.com
IG handle
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Are you currently happy with your morning routine?
Yes
Could be better
I've never had one, but would like to!
Are you currently experiencing any of the following? Check all that apply.
Bloating
Brain Fog
Low Energy/Fatigue
Weight Gain
Trouble Losing Weight
Anxiety
Digestive Issues / Irregular
Acne
Motivation - lack of
Other
Are you currently physically active? I.e pilates, cycling, gym, etc.
I work out 5x per week
I want to start a workout plan
Could be better
Are you familiar with ingredients in wellness & beauty products and how they can affect your overall health?
I'm familiar, but haven't looked more into it
I'm somewhat familiar, but could use more info
I'm an avid reader and into low tox living
I am not familiar, but now interested to know
Are you familiar with gut health and how this can affect your overall health, skin, and mental health?
I'm a gut health enthusiast
I'm familiar but can use more info
I didn't know but now curious
I want to help you! What areas of your life would want to improve? check all that apply.
Overall Wellness
More Community / Friendships
Extra Income / Financial stability
Mental Health / Mindset
Please share any other info that can be helpful for me to provide the best help for you.
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