Wellness Survey
Hi! I’m so grateful you're here. If you could take the next 2 min to fill out as many of these questions as possible to the best of your ability so I can know how to best serve you!! xoxo
Name
First Name
Last Name
Email
example@example.com
Instagram Handle
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Rate your day-to-day energy levels (1-10):
How's your digestion (1-3 solid a day? constipated?)
What are your food cravings? Do you currently eat gluten, dairy, alcohol, coffee, inflammatory foods, etc?
Do you get headaches? If so, how often?
How's your sleep? Do you struggle to fall or stay asleep? Do you use any sleep aids?
How do you feel waking up in the morning? Check all that apply.
refreshed
groggy
foggy
exhausted
starving
Do you have kids? If so, how are their eating habits? Are you interested in kids gut health info?
Can you think of any of your current habits that AREN'T serving you?
Are you intentional about how many grams of protein you consume daily?
Are you currently experiencing any of the following? Within the last month- Check all that apply.
Bloating
Digestive Issues
Low Energy/Fatigue
Anxiety
Brain Fog
Trouble Sleeping
Skin Issues
Weight Loss
Weight Gain
Struggling to Balance Blood Sugar
None of the above
Are you currently satisfied with the look + feel if your skin?
Yes
No
Could be better
Are you experiencing any of these common skin issues? Within the last month-Check all that apply.
Acne
Oily Skin
Dry Skin
Hormonal Breakouts
Signs of Aging
Fine lines / wrinkles
dark spots, age spots, post acne scars
dull skin / uneven skin tone
none of the above
How familiar are you with ingredients in Wellness + Beauty Products and how they can affect your overall health?
I'm familiar- but haven't looked too much 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 it at all
How familiar are you with Gut Health and how it affects your overall health, your skin, and your mental health?
I'm familiar! I nerd out about Gut Health
I'm familiar but could definitely use some more info
Not familiar at all, I'm open to learning!
I want to help you!! How can I best follow up?
product recommendations for your overall wellness
send me a few samples of the products that could help me!
Let's chat about what products would be best for me!
I’m down to set up a time to connect for 20 min and chat
What areas of your life do you feel like you need to focus on right now? Please check all that apply- even if it can't be a short-term focus, it can be a long-term focus!
Overall Wellness
Cleaner, Simpler Products (Non-tox my home)
More community/Higher quality friendships
Extra Income/Financial Stability
Mindset/Mental Health
Grow My Faith
Are you open to opportunities for more income?
Yes
No
Possibly
If yes to the answer above, which income level would be ideal??
$300-$1,000/mo
$1,000-$3,000/mo
$3,000-$12,000/mo
$22,000/mo
Anything helps
Submit
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