Name
First Name
Last Name
Email
example@example.com
IG Handle
Mobile Number
Please enter a valid phone number.
Format: (000) 000-0000.
What is your age range?
18-29
30-39
40-49
50-59
60-69
70-100
What stage are you at in your life?
Looking to improve my over all health
Thinking about or trying to get pregnant
Currently pregnant
Post-partum
Perimenopause or menopause
Are you currently satisfied with your health?
Yes
No
Could be better
Which of these are your top priorities of interest in the next 6-12 months? Check all that apply.
Setting up a foundation of healthy habits
Weight management
Optimizing gut health and/or digestion
Increase my immunity and overall health
Adding more protein
Building muscle
Increasing energy without a crash later in the day
Menopause and/or Perimenopause support
Increase income and/or financial stability
Improve mindset and/or mental health
Join a community and/or increase meaningful friendships
Improve my skin
Find balanced healthy recipes to add to my current cooking routine
Are you looking to build more muscle in the next 6-12 months?
Yes
No
Maybe
What resources have you used in the past? Or where do you typically go to learn more about your health? Check all that apply.
My Doctor
Holistic Doctor or Holistic approach
Nutritionist or Dietician or Trainer
Internet (Includes Social Media, Podcasts, Online articles)
Friends and/or family
Other
Are you currently experiencing any of the following? Check all that apply.
Bloating and/or digestive issues
Low Energy and/or fatigue
Anxiety
Brain fog and/or trouble focusing
Trouble sleeping (Includes going to sleep and staying asleep)
Weight loss
Are you familiar with ingredients in the products you frequently use and how these can impact your overall health?
I'm familiar but don't really care
I'm somewhat familiar but could use some more info
I'm an avid label reader and avoid certain products based on ingredients
I'm not familiar with how ingredients affect my overall health
Are you familiar with your gut health and how it can have an impact on your overall health, your skin, and your mental health?
I'm familiar but could use more info
No
Absolutely, I'm a gut health enthusiast
How is your overall immune function? Is staying healthy important to you?
I'm familiar but could use more info
No
Absolutely, a good immune system is very important to me
Are you currently satisfied with your skin?
Yes
No
Could be better
Are you experiencing any of these common skin issues? Check all that apply.
Acne
Oily skin
Dry and/or itchy skin
Fine lines & wrinkles
Dark spots and/or age spots
Dull skin and/or lacking glow
None of the above
What is your current skin care routine?
Nothing right now
The basics (wash my face, maybe use a moisturizer or sunscreen)
Have a routine but inconsistent with using it
The works, I use it all
I am here to help! How can I best support you and your next step in this journey? Check all that apply!
Send me product recommendations based on this survey
Send me samples of products that might help
Have a quick 15 minute consultation call to discuss survey results, recommendations and next steps
Add me to a community with other individuals who are on a similar journey
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