HEALTH AND WEALTH SURVEY
Health
What type of physical activity do you participate in? (Circle all that apply)
*
Walking
Running
Strength Training
Yoga
Cycling
Swimming
Do you currently have a wearable device?
*
Yes
No
How would you rate your overall strength?
*
Normal
Good
Great
Height
*
Weight
*
List any medications you are currently taking:
*
Wealth
Are you interested in having a TAX FREE income retirement?
*
Please Select
Yes
No
What age would you like to retire?
*
How much money will you need to maintain your lifestyle?
*
Please Select
$100,000
$250,000
$500,000
$1,000,000
$2,000,000
If you start saving today, how much can you save in a month?
*
Please Select
$100
$250
$500
$750
$1,000
$2,000
$2,500+
Do you currently have any of the following?
*
IRA
401K
403B
STOCKS
BONDS
MUTUAL FUNDS
CD
ANNUITY
LIFE INSURANCE
HAVE NO PLAN
NOT COMFORTABLE
COMFORTABLE
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Best Date
*
-
Month
-
Day
Year
Date
Best Time to call
*
SS#
ID Type
*
ID#
*
Submit
Should be Empty: