Wellness Assessment

Wellness Assessment

Hi there! My name is Celina and I’m a health and wellness advocate. I am passionate about helping friends get to the root cause of their health concerns, increase their natural energy levels, and ultimately feel their best while improving their overall health.
Full Name

First NameLast Name
E-mail
example@example.com
Do you have any current health concerns or suffer from any health conditions?
Are you satisfied with your current health?
Are you satisfied with your current weight?
Are you satisfied with your energy levels? (Scale of 1-5 with 1 being “I feel sluggish most days and don’t have enough energy throughout the day.” and 5 being “I have tons of energy everyday!”)

1

2

3

4

5

1 is I don't have enough energy, 5 is I have tons of energy everyday
Are you satisfied with your current mood?
How is your water intake? (Scale of 1-5 with 1 being “I don’t drink much water daily. I drink a lot of coffee/tea, energy drinks, pop, etc” and 5 being “I drink tons of water everyday!”)

1

2

3

4

5

1 is I don't drink much water daily, 5 is I drink tons of water everyday
Do you exercise?
What areas of your health are you looking to improve? (Check all that apply)
What are your top health goals?
Do you struggle with any of the below symptoms? (Check all that apply)
What do you feel like is holding you back the most from what you want?
Would like to try a FREE sample of one my favorite supplements?*
What’s the best way for us to connect?
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