Fresh Start Health Survey
Julie Ryan Shiroma l Mom After 40
Full Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
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Gender
Please Select
Male
Female
Age
18-25
26-34
35-54
55-64
65+
What is frustrating you most in your health?
I want to lose weight
I have low energy and live for naps
I don't sleep well.
I crave sugar all the time
My moods are unpredictable
I am stressed
My joints/body aches
I am bloated
I am having GI issues
I am not as active as I would like to be
I feel like I am doing all the right things but nothing is changing
Other
How would you describe your eating habits
Low Fat
Low Carb
High Protein
Vegetarian or Vegan
I eat what I want
Daily Movement
Stuck to the couch
On my feet for work
Getting 10,000 steps daily
I live at the gym
Describe your energy level
Exhausted all the time
Crash in the afternoon
Steady all day
Energizer bunny
Stress level
Not Stressed
A little Stessed
Very Stressed
How much are you sleeping at night
8-10
6-8
Less than 6
I wake up frequently
Do you get half your body weight in ounces of water daily? If not, how much do you get?
What medications are you currently taking?
On a scale of 1-10 how ready are you for change?
What else would you like me to know?
Are you currently working with a Plexus Ambassador?
Yes
No
What is the best way to follow up with you?
Text Message
Phone Call
Email
Instagram Messenger
Facebook Messenger
Submit
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