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)*

Improve my Gut Health and General Well-beingImprove my skin and beautyLose weight and increase my energy levelsImprove my chronic health/inflammation and Pain
What are your top health goals?*
Do you struggle with any of the below symptoms? (Check all that apply)*

Mood swingsBrain fogAcid refluxBloatingChronic fatigueConstipationChronic joint painFrequent yeast infectionsIBSLeaky gutFrequent illnessSinus issues/allergiesRashes/Eczema/PsoriasisAutoimmune disorder (i.e. thyroid, diabetes, chrons, pcos, etc)AsthmaFood intolerancesAnxiety/depressionNone of the above
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?**

Gut health and wellness drinkCravings control drinkClean energy drinkKids Microbiome gut health drinkBlood sugar regulating drinkNot at this time
What’s the best way for us to connect?*

EmailSocial MediaZoom call please!
Should be Empty: