Gut Health Questionaire
Name
First Name
Last Name
E-mail
example@example.com
Phone Number
-
Area Code
Phone Number
Gender
Male
Female
Age
18-25
26-34
35-44
45-54
55-64
65+
What is your level of daily movement?
Not very active
Slightly active
Moderately active
Highly active
How would you rate your energy levels?
Poor
Fair
Good
Very good
How would you rate your stress levels?
Not stressed
Somewhat stressed
Very stressed
How would you rate your anxiety?
Type option 1
Type option 2
Type option 3
Type option 4
How would you rate your anxiety?
Never anxious
Somewhat anxious
Very anxious
Do you experience symptoms from an autoimmune disease?
No
Yes
Sometimes
How many hours of sleep do you get each night?
8-10
6-8
Less than 6
Your current diet would 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
Better immune health
Stronger skin, hair, nails
Better digestion
Improved mental health
Clearer skin
Better nutrition
More exercise
Better focus
Other
Please rate your readiness for change:
1 - not ready
2
3
4
5
6
7
8
9
10 - very ready
Timeline for achieving your goal.
Rows
Now
2 Months
4 Months
6 Months
One Year
Goal
Is there anything else you would like for me to know?
Are you currently working with a Plexus ambassador?
Yes
No
What is the best way to follow up with you?
Text Message
Phone Call
Email
Instagram DM
Instagram Handle
Address
Please Select
Canada
USA
Australia
Mexico
Submit
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