Healthy Starts Here!
Tina Baden, DNP CNP Brand Ambassador
Health Questionnaire
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Age
18-25
26-34
35-44
45-54
55-64
65+
What's your level of daily movement?
Not very active
Slightly Active
Moderately Active
Highly Active
How would you rate your energy levels?
Poor
Fair
Good
Very Good
How many hours do you sleep?
More than 10
9-10
8-9
7-8
6-7
Less than 6
Your current diet could be best characterized as:
low-fat
low-carb
high-protein
Vegetarian/Vegan
No special diet
What are your health goals?
More energy
Weight Loss
Better Sleep
Healthier Skin, Hair, Nails
Overall gut health
Better Immune Health
Better focus
Other _______________
Please rate your readiness for change.
1
2
3
4
5
6
7
8
9
10
Is there anything else you would like me to know?
What is the best way to follow up with you?
*
Text Message
Phone call
Email
Submit
Should be Empty: