Wellness Survey

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 NameLast Name
Email
example@example.com
Instagram Handle
Phone Number
Please enter a valid phone number.
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.

refreshedgroggyfoggyexhaustedstarving
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.

BloatingDigestive IssuesLow Energy/FatigueAnxietyBrain FogTrouble SleepingSkin IssuesWeight LossWeight GainStruggling to Balance Blood SugarNone of the above
Are you currently satisfied with the look + feel if your skin?

YesNoCould be better
Are you experiencing any of these common skin issues? Within the last month-Check all that apply.

AcneOily SkinDry SkinHormonal BreakoutsSigns of AgingFine lines / wrinklesdark spots, age spots, post acne scarsdull skin / uneven skin tonenone 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 itI'm somewhat familiar- but could use some more infoI'm an avid label reader and into low-tox livingI'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 HealthI'm familiar but could definitely use some more infoNot familiar at all, I'm open to learning!
I want to help you!! How can I best follow up?

product recommendations for your overall wellnesssend 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 WellnessCleaner, Simpler Products (Non-tox my home)More community/Higher quality friendshipsExtra Income/Financial StabilityMindset/Mental HealthGrow My Faith
Are you open to opportunities for more income?

YesNoPossibly
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/moAnything helps
Should be Empty: