Name
First Name
Last Name
Email Address
example@example.com
Phone number
If you could waive a magic wand when it comes to your hair, skin, health, mood and energy what would you want? Be specific
Rate your day to day energy levels (1 10)
Do you struggle with mental health?
Do you have any medical conditions currently? Auto immune, allergies
Do you take any medications or supplements? If so what supplements do you take?
How is your digestion? (great= 1-3 poops/day) Do you struggle with constipation? Liquid lava? Bloated? Gassy? How’s the smell?
What’s your resilience to sickness on scale of 1-10? (10 being you never get sick)
What does your current diet look like? (Dairy, gluten, coffee, alcohol, sugar)
Do you have any food cravings?
Do you want more easy healthy recipes for the whole family?
How many Grams of protein a day do you typically have?
How's your sleep? Do you struggle to fall or stay asleep? If so do you take anything for it?
How do you feel waking up in the morning? Refreshed, groggy, foggy, exhausted, starving?
Do you workout? Is so how often & what type of workouts
Check what your interested in
Mental Health
Hormones
Weightloss
Kids Nutrition
Detoxing
Parasites & GI cleansing
Clean Skincare
Non Toxic makeup
Holistic alternatives To Pharm meds (neutraceuticals)
Holistic Cancer Resources
AutoImmune
How committed are you to getting healthy in 2024?
What are some habits that aren't serving you?
Do you desire more community and connection?
What's your goals for this next 90 days? Personal, work, family, health etc
Do you want more info on the gut reset? (phase 1 of healing)
Do you want more info on the GI Cleanse? (phase 2 of healing)
Are you open to other opportunities for more income? Yes, no or possibly
Submit
Should be Empty: