Wellness Survey
Cassie Smith
Full Name
*
First Name
Last Name
E-mail
*
example@example.com
IG handle
Phone Number
please enter a valid phone number
Are you currently experiencing any of the following? Check all that apply
Bloating
Digestive Issues
Low Energy/Fatigue
Infrequent Bowel Movements
Anxiety
Brain fog
Trouble Sleeping
Skin issues
Weight loss
Weight gain
Blood sugar balance
None of the above
Do you have any medical conditions? Autoimmune, allergies, etc?
Are you pregnant or nursing? If pregnant, how far along? If nursing, how old is your baby?
Are you currently satisfied with the look/feel of your skin?
yes
no
could be better
Are you experiencing any of these common skin issues? Check all that apply
Acne
Oily Skin
Dry Skin
Sings of Aging
Fine lines/Wrinkles
Dark spots/ Age apots/ Post Acne Scars
Dull skin/ uneven skin tone
2 or more of these areas
none of the above
Are you familiar with ingredients in wellness and beauty products and how they affect your overall health?
I'm familiar, but haven't thought about looking into it.
I'm somewhat familiar, but could use some more info.
I'm an avid label reader and into low-tox living
I'm not familiar with how ingredients affect my overall health
I want to help you! How can i best follow up?! Check all that apply
Product recommendations for your overall wellness
Send me samples of product that could help!
Let's chat about what products would be right for me!
I'm interested in 1:1 workout/nutrition coaching
What areas of your life would you want to improve?
Overall Wellness
More Community/Friendships
Extra Income/ Financial Stability
Mindset/Mental Health
Are you open to opportunities for more income?
yes
no
possibly
If yes to the above, what income level would be ideal?
$300-$1,000/month
$1,000-$3,000/month
$3,000-$12.000/month
$22,000/month
anything would help
Any other questions, thoughts or concerns?
SUBMIT
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