Wellness Survey
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Instagram handle
Are you currently experiencing any of the following? Check all that apply.
Bloating
Digestive issues
Low energy/fatigue
Anxiety
Brain fog
Trouble sleeping
None of the above
Are you currently satisfied with 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 or wrinkles
Dark spots
Dull skin
Sensitive skin
None 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 care
I'm somewhat familiar but could use some more info
I'm an avid label reader, passionate about low-toxin 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 somewhat familiar
Yes, I'm a gut health enthusiast
No
I want to help you in any way I can! How can I best follow up? Check all that apply.
Product recommendations for my overall health and wellness
Product recommendations for my skin
Send me samples of products that might help me
Add me to your VIP group so I can access info on these topics
Invite me to virtual wellness workshops
Invite me to local in-person wellness workshops
What areas of your life do you want to improve? Check all that apply.
Overall wellness
Athletic performance
More community/friendships
More income/financial stability
Mindset/mental health
Do you have any other comments regarding this survey?
Are you open to hopping on a quick 15 minute consultation call to discuss your survey?
Yes!
Not right now
Thank you for taking the time to complete my survey!
- Andrea
Submit
Should be Empty: