HEALTH AND WEALTH SURVEY

HEALTH AND WEALTH SURVEY
Health
What type of physical activity do you participate in? (Circle all that apply)*

WalkingRunningStrength TrainingYogaCyclingSwimming
Do you currently have a wearable device?*

YesNo
How would you rate your overall strength?*

NormalGoodGreat
Height*
Weight*
List any medications you are currently taking:*
Wealth
Are you interested in having a TAX FREE income retirement?*
What age would you like to retire?*
How much money will you need to maintain your lifestyle?*
If you start saving today, how much can you save in a month?*
Do you currently have any of the following?*

IRA401K403BSTOCKSBONDSMUTUAL FUNDSCDANNUITYLIFE INSURANCEHAVE NO PLANNOT COMFORTABLECOMFORTABLE
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Best Date*

MonthDayYear
Date
Best Time to call*
SS#
ID Type*
ID#*
Should be Empty:

Health