Your Wellness Journey Starts Here
Jessica Waters | drinkpinkjess@gmail.com
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Gender
Female
Male
Age
Please Select
18-25
26-34
35-44
45-54
55-64
65+
What's your level of daily movement?
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Not Very Active
Slightly Active
Moderately Active
Highly Active
How would you rate your energy levels?
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Poor
Fair
Good
Very Good
How would you rate your stress levels?
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Not Stressed
Somewhat Stressed
Very Stressed
How many hours of sleep do you get each night?
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Less than 6
6-8
8-10
Your current diet could best be characterized as:
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Low-fat
High-Protein
Low-carb
Vegetarian
Vegan
No Special Diet
What are some of your health goals? Select all that apply.
More Energy
Weight Loss
Better Sleep
Stronger Hair, Skin & Nails
Better Digestion
Better Immune Health
Better Nutrition
Improved Skin Health
More movement/exercise
Better Focus
Other
Please rate your readiness for change, 10 being the highest.
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10
9
8
7
6
5
4
3
2
1
What is your goal timeline?
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8 Weeks
16 Weeks
24 Weeks
32 Weeks
40 Weeks
1 Year
unknown
Are you pregnant/ breastfeeding?
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Yes, pregnant
Yes, breastfeeding
May be pregnant
Do you currently take an iron supplement?
Please Select
Yes
No, but I should
No, my iron levels are good
I’m not sure what my current iron levels are
Do you have any allergies?
Studies show that starting your health journey with a friend significantly increases your chances of success! Can you think of 3 people who might be facing some of the challenges or could be ready for a positive change?
Are you currently working with a Plexus Ambassador
Yes
No
What is the best way to follow up with you? Select all that apply.
Text Message
Phone Call
Email
Instagram Messenger
Facebook Messenger
Are you interested in hearing how you can get your products paid for and/or earn an extra stream of income?
Please Select
Yes, I'd love to have my products paid for.
Yes, I'd love to learn more.
Hmmm, maybe
Not at this time.
Is there anything health-related (allergies, conditions, etc.) that I should know about?
Thank you for taking the time to fill out the questionnaire! I will be in touch with you shortly!
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