Health & Wellness Questionnaire
Name
*
First Name
Last Name
Age
How did you hear about us?
Instagram
Youtube
AM Healthcare/After Action
Other
E-mail
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Text messages ok?
*
Yes
No
Are you a First Responder?
*
Yes
No
Occupation
*
What do you consider your biggest health and wellness challenge currently? Choose all that apply.
*
Chronic Pain
Low Energy
Anxiety
Losing Weight
Time Management
Sugar Addiction
Endless Cravings
Digestive Issues
Trouble Sleeping
Emotional Eating
Brain Fog
Low Immune system
Stress
Skin Issues
Other
What are your biggest health and wellness challenges currently?
What do you feel is the biggest obstacle holding you back from overcoming your pain points? Choose all that apply.
*
Time
Burned out, Overwhelm
No support from friends or family
No support from a wellness or health professional
Too much conflicting information out there and don't know where to begin
Tried before and failed so afraid to attempt it again
Don't know what to eat or cook, need recipes
Know what to do, but hard to implement into daily routine
Other
What are your favorite ways to learn when it comes to your health and wellness? Choose all that apply.
*
Written text (PDFs, books, manuals, etc.)
Video
Audio
Group coaching
One on one coaching
Virtual webinars
Live in-person workshops or events
Facebook Groups
Other
What are you interested in learning? Choose all that apply.
*
How to build your immune system
How to reduce sugar
How to plan healthier meals/recipes/shopping lists
How to have a happy healthy gut
How to improve mindset/mental wellness
How to curb emotional eating/end cravings
How to make healthy habits stick
Virtual Fitness Programs you can do at home
How to lose weight and keep it off
How to eat healthier on a low budget
How to make healthier meals
Time-saving healthy tips for busy people
How to add supplementation
What is your biggest challenge, frustration, and/or fear when it comes to your health and wellness goals?
*
On a scale of 0 to 10, what number would you say you are at today in regards to being ready to implement changes to achieve your health goals? (0= Not ready 10= Ready to change today!)
*
Submit
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