Wellness Survey
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
IG handle (if you don’t have Instagram just type n/a)
Are you currently experiencing any of the following? Check all that apply.
Bloating
Digestive issues
Low energy/fatigue
Autoimmune disorders
Anxiety
Brain fog
Trouble sleeping
None of the above
Menopausal symptoms
Menstrual discomfort
Frequent UTIs
Overeating
Are you currently satisfied with your skin/skincare routine?
Yes
Could be better
No
Are you currently experiencing any of the following common skin issues?
Acne
Eczema
Oily skin
Dry skin
Signs of aging
Fine lines/wrinkles
Dark spots/age spots
Dull skin/lacking glow
None of the above
Are you familiar with ingredients in wellness/beauty products and how these can affect overall health?
I’m familiar but don’t really care
I’m somewhat familiar but could use some info
I’m an avid label reader and all about the low tox life
I’m not familiar with how ingredients affect my life but am willing to learn
Are you familiar with gut health and how it can affect your overall health, skin, & mental health?
I’m familiar but would love more info
Yes! I’m a gut health enthusiast!
No but I’m open to learning
Not really interested
I want to help you in any way I can! How can I best follow up?! Check all that apply
Product recs for skin and overall wellness
Add me to your VIP Facebook group so I can follow along for more info
Information on building an income with arbonne
What areas of your life do you want to improve? Check all that apply
Overall wellness
More community/friendships
More income/financial stability
Mindset/mental health
Are you a mama?
Yes
No
I’m currently expecting!
If you have young children/are expecting, are you currently breastfeeding?
Yes
No
I plan to
N/A
Are you open to hopping on a quick 15 min consultation call to discuss your survey?
Yes
Not at this time
Submit
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