Wellness Survey

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Instagram handle

How do you prefer to be contacted?

What are you looking for support with (check all that apply)

If other, what are you looking for support with?

Rate your day to day energy levels (1-10)

What's your resilience to colds/sickness? (1-10, 10 being you never get sick)

Do you struggle with anything mentally/emotionally? Anxiety, depression, irritability/rage, ADD, overstimulation, insomnia, stress, feeling numb or checked out, etc

Do you have any recurring/chronic pain? (incl. migraines/headaches, back pain, fibromyalgia, arthritis, nerve pain, soreness/injury)

How's your sleep? Do you struggle to fall or stay asleep? Do you use any sleep aids?

How do you feel waking up in the morning? Refreshed, groggy, exhausted, starving

How's your digestion? (Healthy movements daily, any bloating or IBS-type symptoms?

Are you happy with your current body weight and strength? Do you want to gain or lose any weight? Build strength/increase muscle?

Do you have kids? If so, are you interested in learning about holistic supports for them?

Are you interested in healthy recipes for the whole family, healthy swaps, snack and meal ideas?

How many grams of protein do you typically have in a day?

Do you take any medications or supplements?

What are some habits that aren't serving you?

How committed are you to getting healthier (mentally and/or physically) and feeling better within the next year?

Do you believe it's possible to feel better and do you believe you're worthy of feeling your best?

Do you trust that I can help you? Why or why not

Do you desire more community and connection with positive, wellness-minded people?

Where do you live?

Are you open to other opportunities for more income, or interested in getting wellness products for free? Yes, no, or possibly

If you could wave a magic wand when it comes to your mood, sleep, energy, pain, strength/weight, gut health, hair/skin/nails, what would you want? Be specific.

What are your goals for the next 90 days? (Health, personal, family, business, financial)

Want more info on

Have you used CBD before? If so, what were your results? What brand/product did you use?

Do you have any issues with a small, legal, non-intoxicating amount of THC (.3%) in your products? *You may want to avoid this if you're routinely drug tested

There are two ways to take CBD - tincture (oil) form or jelly (gummy) form. Which do you prefer?

While the effects of CBD are sometimes seen quickly, it's not uncommon for it to take several weeks to fully experience results. Are you willing to give CBD a minimum of 6-8 weeks of consistency?

Thank you for taking the time to fill this out! Can't wait to be in touch soon. Feel free to use the space below to share anything else you'd like me to know!