Wellness Survey

Wellness Survey
Name*

First NameLast Name
Email*
example@example.com
IG handle
Mailing address (so we can mail you your freebie!)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Are you currently experiencing any of the following? Check all that apply.

BloatingDigestive IssuesLow Energy/FatigueAnxietyBrain FogTrouble SleepingSkin issuesWeight lossWeight gainBlood sugar imbalanceNot eating enough or getting enough nutrients
How do you feel about the current condition of your skin?

Love itCould 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 which products may be right for me based on my answers!Set up a 1:1 potential business partner discovery callI want to host to save more!
What areas of your life would you want to improve? Check all that apply!

Overall WellnessMore Community/FriendshipsExtra Income/Financial StabilityMindset/Mental health
Would you like to be added to my Nurtured by Nature Community FB Group? It's free to join and open to all!

Yes, please add me!Maybe another time, thanks
Do you have any allergies or food sensitivities?
Should be Empty: