Wellness Survey
Jenell Steele
Name
First Name
Last Name
Email
example@example.com
IG handle
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Are you currently experiencing any of the following? Check all that apply.
Bloating
Digestive Issues
Low Energy/Fatigue
Brain Fog
Trouble Sleeping
Skin issues
Weight loss
Weight gain
Blood sugar balance
None of the Above
What do you need help with the most? What encouraged you to fill out this survey?
How is your daily digestion? (1-3 solid a day? constipated etc?)
Are you currently satisfied with the look/ feel of 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
Dull skin/ Uneven Skin Tone
2 or More of These Areas
None 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 it
I’m somewhat familiar, but could use some more info
I’m an avid label reader and into low-tox living
I’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 info
Yes! I’m a gut health enthusiast
No
I want to help you! How can I best follow up?! Check all that apply
Lifestyle recommendations for your overall wellness
Let's chat about what products would be right for me!
I'm interested in 1:1 accountability coaching
What areas of your life would you want to improve? Check all that apply!
Overall Wellness
More Community/Friendships
Extra Income/Financial Stability
Mindset/Mental health
Are you open to opportunities for more income?
yes
no
possibly
Any other questions, thoughts, goals or concerns
Submit
Should be Empty: