Lifestyle Questionnaire
How important is nutrition in your life?
Very Important
Important
Neutral
Somewhat Not Important
Not Important at All
How important would you like nutrition to be in your life?
Very Important
Important
Neutral
Somewhat Not Important
Not Important at All
How often do you engage in physical activity?
Every day
3-4 times per week
1-2 times per week
Never
How often would you like to engage in physical activity?
Every day
3-4 times per week
1-2 times per week
Never
Do you have kids?
Yes
No
I’m pregnant
Do you currently take any vitamins or supplements?
Yes
No, but I would like to
No and I do not want to
If you have children, do they take any vitamins or supplements? (Ages 4 +)
Yes
No, but I would like them to
No and I don’t want them to
I don’t have children or they’re under the age of 4
Do you have any of the following minor health challenges?
Headaches
Joint pain
Trouble sleeping
Fatigue
High Cholesterol
Digestion
Other
None
How do you decide which cleaning products to use in the home?
Quality
Price
Environmentally Friendly
Recommendations From Friends
Other
How frequently do you wear makeup?
Every day
3-4 times per week
1-2 times per week
Only For Special Occasions
Never
How do you decide which brand of makeup to use?
Quality
Price
Recommendations From Friends
Skin Health
Cruelty Free or Vegan
Other
How important is skincare in your life?
Very Important
Important
Neutral
Somewhat Not Important
Not Important at All
How important would you like skincare to be in your life?
Very Important
Important
Neutral
Somewhat Not Important
Not Important at All
How do you decide which brand of skincare to use?
Quality
Price
Recommendations From Friends
Skin Health
Cruelty Free or Vegan
Other
How do you decide which hair products to use?
Recommendations From Friends
Quality
Price
To help with a specific treatment (Color safe, moisturizing, hair loss, dandruff, etc.)
Other
Name
First Name
Last Name
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