Mountain Mama Wellness
A Holistic Approach with a focus on healing.
Name
First Name
Last Name
Which of these best describe your eating habits?
Vegetarian
Vegan
Diabetic
Gluten Free
No rescrictions
Dairy Free
I am picky
Other
Tell me which of these that you struggle with the most:
Weight management/metabolism
Anxiety
Perimenopause or menopause symptoms including bloating, lack of energy, belly weight gain
Digestion issues
Lack of energy
Trouble sleeping
IBS/Chronic Constipation
Other
What does your current diet consist of?
Salad
Vegetables
Chicken
Sandwiches
Casseroles
Pasta, Lasagna
Burgers and fries
Sandwiches
Eating Out Too Much
Other
What type of eater are you in general?
Big eater
Moderate eater
Light eater
Quick and easy
I am always hungry
I crave sweets
Other
How would you describe your diet?
Healthy and balanced
OK
Poor
Fast food and energy drinks
Other
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Did anyone refer you?
Submit
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