Healthier & Happier
Becca Lardy | beccasmith09@yahoo.com
Full Name
First Name
Last Name
Contact Number
Format: (000) 000-0000.
Email Address
example@example.com
What is your age?
18-25
26-34
35-44
45-54
55-64
65+
What is your gender?
Please Select
Male
Female
N/A
What is your level of daily movement?
Mostly Sedentary
Slighty 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 at all
Somewhat stressed
Very stressed
How many hours a night do you sleep?
Less than 6
6-8
8-10
Your current diet could be best described as:
Low-fat
Low-carb
High protein
Vegetarian/vegan
No special diet
What are your health goals/concerns?
More Energy
Weight Loss
Better Sleep
Better skin, stronger nails, healthier hair
Better Digestion/Bowel Regularity
Increase Immune Health
Clearer Skin
Healthier Nutrition
More Exercise
Better Focus
Decrease Stress/Anxiety
Please rate your readiness for change
1-not too ready
2
3
4
5
6
7
8
9
10-SO READY
Is there anything else you would like me to know?
Are you currently working with a Plexus Ambassador?
Yes
No
Are you looking to earn money/work with me?
YES
NO
What is the best way for me to follow up with you?
Text Message
Phone Call
Email
Facebook Messenger
Instagram Messenger
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