Gut health questionnaire
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Gender
Female
Male
Age
18-25
26-34
35-44
45-54
55+
What’s your level of daily movement?
Not very active
Slightly active
Moderately active
Highly active
How would you rate your energy level?
Poor
Fair
Good
Very good
How would you rate your stress level?
Not stressed
Somewhat stressed
Very stressed
How many hours a night do you sleep?
8-10
6-8
Less than 6
Your current diet could be characterized as:
Low-fat
Low - carb
High - protein
Vegetarian/Vegan
No special diet
What are some of your health goals?
More energy
Weight loss
Better sleep
Stronger hair, skin, nails
Better digestion
Better immune health
Clearer skin
Better nutrition
More exercise
Better focus
Other
Please rate your readiness for change
1
2
3
4
5
6
7
8
9
10
Timeline for achieving your goal
8 weeks
16 weeks
24 weeks
32 weeks
40 weeks
1 year
Is there anything else you would 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
Should be Empty: