Wellness Survey

Wellness Survey!

From Lauryn Breckner
Name

First NameLast Name
Email
example@example.com
Instagram Username
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Are you currently experiencing any of the following? Check all that apply.

BloatingDigestive IssuesLow Energy/FatigueAnxietyBrain FogTrouble SleepingSkin issuesWeight lossWeight gainBlood sugar balanceNone of the Above
Are you currently satisfied with the look/ feel of your skin?

YesNoCould Be Better
Are you experiencing any of these common skin issues? Check all that apply.

AcneOily SkinDry SkinSigns of AgingFine lines/WrinklesDark spots/Age spots/ Post Acne ScarsDull skin/ Uneven Skin Tone2 or More of These AreasNone of The Above
Are you familiar with ingredients in wellness and beauty products and how they can affect your overall health?

I’m familiar, but haven't thought about looking into itI’m somewhat familiar, but could use some more infoI’m an avid label reader and into low-tox livingI’m not familiar with how ingredients affect my overall health
Are you familiar with gut health and how this can affect your overall health, your skin, and your mental health?

I’m familiar but could use more infoYes! I’m a gut health enthusiastNo
I want to help you! How can I best follow up?! Check all that apply

Product recommendations for your overall wellnessLet's chat about what products would be right for me!
What areas of your life would you want to improve? Check all that apply!

Overall WellnessMore Community/FriendshipsExtra Income/Financial StabilityMindset/Mental health
Should be Empty:

Wellness Survey!