Living Fully, Healthier & Happier
Natalie Passmore | Health Coach & Emerald Plexus Brand Ambassador
Full Name
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Gender
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Male
Female
Age
18-25
26-34
35-44
45-54
55-64
65+
What is 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 would you rate your stress level?
Not Stressed
Somewhat Stressed
Very Stressed
How many hours a night do you sleep?
8-10
6-8
Less than 6
Your current diet could be best characterized as:
Low-Fat
Low-Carb
High Protein
Vegetarian-Vegan
No Special Diet
What are some of your health goals?
More Energy
Weight Loss
Better Sleep
Stronger Hair, Skin & Nails
Better Digestion
Immune Health
Clearer Skin
Better Nutrition
More Excercise
Better Focus
Other
Please rate your readiness to change (1 being semi ready and 5 being ready to change now)
1
2
3
4
5
Timeline for achieving your goals
Rows
2 Months
4 Months
6 Months
8 Months
10 Months
1 Year
Now
Is there anything else you would like me to know?
Are you currently working with a plexus ambassador?
Yes
No
What is the best way to follow up?
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