Healthy From the Inside Out
Brittney Hendrix britthendrix908@gmail.com
Name
First Name
Last Name
Gender
Female
Male
Age
18-25
26-34
35-44
45-54
55-64
65+
What’s your level of daily movement?
Not very active
Slightly active
Moderately active
Highly active
How would you rate your energy levels?
Poor
Fair
Good
Very good
How would you rate your stress level?
Not stressed
Somewhat stressed
Very stressed
How many hours a night do you sleep?
8-10
6-8
Less than 6
Your current diet could be best characterized as:
Low fat
Low carb
High protein
vegetarian/vegan
Gluten free
no special diet
What are some of your health goals?
More energy
Weight loss
Better sleep
Stronger hair, skin, nails
Better digestion
Better immune health
Better nutrition
More exercise
Better focus
Other
Please rate your readiness for change:
1
2
3
4
5
6
7
8
9
10
Is there anything else you’d like me to know?
Are you currently working with a Plexus Ambassador?
Yes
No
Are you curious about the Income Opportunity with me?
Please Select
Yes
What is the best way to followup with you?
Text message
Phone call
Email
Instagram message
Facebook message
Submit
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