Tell me about you!
KPlex Wellness | KPlexWellness@gmail.com
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Age
18-25
26-34
25-44
45-54
55-64
65+
What's your daily activity level?
Not very active
Slightly active
Moderately active
Highly active
How would you rate your energy level?
Poor
Fair
Good
Very good
How would you rate your stress level?
Not stressed
Somewhat stressed
Very stressed
How many hours of sleep do you get each night?
8-10
6-8
less than 6
Your current diet could be best characterized as:
Low fat
Low carb
High protein
Vegetarian/Vegan
No special diet
What are some of your health goals? Select all that apply.
More energy
Weight loss
Better sleep
Healthier skin, hair & nails
Better digestion
Better immune health
Better nutrition
More movement/exercise
Better focus & brain health
Other
Please rate your readiness for change, 10 being the highest.
1
2
3
4
5
6
7
8
9
10
Timeline for achieving your goal:
Rows
2 months
4 months
6 months
8 months
10 months
1 year
Now
Your membership comes with a referral link! Which of these is of most interest to you?
Get my products paid for
Earn $100/month
Earn $300/month
Earn $500/month
Earn $1000+/month
Does the opportunity to earn free trips & gifts interest you?
Yes!
No thanks
What questions do you have for me? Or, is there anything else you'd like me to know?
What is the best way for us to communicate? Select all that apply.
Text Message
Phone Call
Email
Instagram Messenger
Facebook Messenger
Thank you for taking the time to fill out the questionnaire! I will be in touch with you shortly!
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