Health Questionnaire
Abigail • The Holistic Way Co
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Gender
Female
Male
Age
18-25
26-34
35-44
45-54
55-64
65-75
75+
Other
What's your level for daily movement?
Not very active
Moderately active
Highly active
Currently injured
Other
How would you Rate your energy levels?
Poor
Fair
Good
Very good
What would you rate your stress levels?
Low
Medium
High
Very high
How many hours of sleep do you get per night?
4-6
6-8
8-10
Other
Your current diet could be best described as:
Low fat
Low carb
High protein
Vegan
Balanced & intuitive eating
Keto
Other
What are you some of health goals?
More energy
Better sleep
Weight loss
Stronger skin & nails
Better digestion
Better immune health
More exercise
Better focus and concentration
All of the above
Other
Please rate your readiness for change on a scale of 1-10.
Are you currently working with a Plexus Ambassador?
Yes
No
How is the best way to follow up with you?
Phone call
Text Message
Email
Instagram Messanger
Facebook Messanger
Whatsapp
Submit
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