Wellness Survey
I'm so excited to connect and help you on your journey to feeling your best and becoming your healthiest self. These questions will help me get to know you better and how I can best serve you. Thank you so much for filling this out and letting me be part of your wellness journey.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Instagram Handle
Are you currently satisfied with your health?
Yes
No
Could be better
Are you currently experiencing any of the following? Check all that apply.
Bloating
Weight Management Issues
Digestive Issues
Low Energy/Fatigue
Anxiety/Depression
Brain Fog
Trouble Sleeping
Regularity
Other
Hows your digestion 1-3 solid 💩a day? constipated at all? Is the smell super fowl? Bloating?
Do you have any medical conditions currently? Autoimmune, allergies etc
Are you currently satisfied with your skin?
Yes
No
Could be better
Are you experiencing any of these common skin issues? Check all that apply.
Acne
Oily Skin
Dry Skin
Signs of aging
Fine lines/wrinkles
Dark spots/age spots
Dull skin/lacking glow
None of the above
Are you familiar with ingredients in wellness and beauty products and how these things can affect your overall health?
I'm familiar but don't really care
I'm somewhat familiar but could use some more info
I'm an avid label reader and all about that low-tox life
I'm not familiar with how ingredients affect my overall health
Do you have kids? If so, are you interested in holistic kids nutrition information?
What are some habits that aren't serving you?
What foods do you eat? Gluten, Dairy, Alcohol, Coffee, Inflammatory oils?
Do you want more easy healthy recipes for the whole family?
Do you want more easy healthy recipes for the whole family?
Yes
No
Do you trust that I can help you? If so, why or why not?
How committed are you to getting healthy in 2026?
Check the boxes of what you are interested in
Mental Health
Kids health & nutrition
Detoxing
Parasites/GI issues etc
Weightloss
Overall Wellness
Personal Growth
Income/Financial Stability
Is there anyone you want to do the reset program with for accountability?
If you could waive a magic wand when it comes to your hair, skin, health, mood, and energy, what would you want? Be specific.
Do you want to work with a holistic practitioner, Naturalpath, or functional medicine?
Do you want more info on the gut reset phase 1 of healing?
Do you want more info on the GI Cleanse phase 2 of healing?
Are you open to other opportunities for more income? Yes, no, or possibly.
If yes to the answer above, check the income level that would be ideal:
$300-$1,000/mo
$1,000-$3,000/mo
$3,000-$12,000
$22,000/mo
I want to help you in any way I can! How can I best follow up? Check all that apply
Product recomendations for your gut health, skin, or overall wellness
Send me samples of things that might help!
I really need support and accountability
Other
Are you interested in hosting a Text Party? I give awesome gifts🤍
Yes
No
I'd Like more information
Are you open to hoping on a quick 15 minute consultation call to discuss your survey?
Yes!
Not right now
Submit
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