Health & Wellness Survey
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Instagram Handle
Are you a mom?
Yes
No
Currently pregnant
Planning to be someday
Are you currently experiencing any of the following? Check all that apply.
Bloating
Digestion Issues
Low Energy/Fatigue
Anxiety
Brain Fog
Trouble Sleeping
Bowel movement irregularities
Cravings
Are you currently happy with 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
Fine lines/Wrinkles
Eczema/Rosacea
Puffyness/Dark under eye circles
None of the above
Do you wear makeup?
Yes, daily
Only on special occasions
Sometimes mascara
Other
Never
Are you open to a quick chat about your survey? (No sales or pressure, just a chat!)
Yes
No
My goal is to help women thrive - by creativing positive habits in their lives that they can feel good about. What resources can I provide you that might be of interest to you? Check all that apply.
Podcasts and book recommendations
Send me the details about the monthly Healthy Habits Club
Product recommendations for skin or gut health
Are you interested in free samples?
Sure, I love trying new things!
No thanks
Do you have any questions or comments for me? I'd love to hear them!
Submit
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