Health Goal Form
This is a super quick survey that helps me get to know you better, so I can recommend the best plan for you!
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What are your current health goals? (Check all that apply.)
More energy
Better sleep
Weight loss
Improved digestion/gut health
Balanced blood sugars
Less bloating
Hormone support
Immune support
Clearer skin
Mood/stress support
What’s your biggest struggle right now when it comes to your health?
How do you feel most days?
Exhausted and dragging
Pretty good, but not great
I feel amazing and want to maintain that
It depends on the day
How is your digestion/gut health?
Constant bloating or discomfort
Regular constipation or bathroom issues
It’s okay, could be better
No complaints!
How many sodas, energy drinks, or sugary snacks do you usually have per day?
None
1-2
3 or more
I’m not sure, but I crave sugar often
Do you currently take any supplements?
Yes, daily
Occasionally
No, but I’m open to it
No, and I don’t really want to
Do you have any specific conditions or concerns you think I should know about (diabetes, thyroid, etc)?
What’s your biggest motivation for improving your health right now?
What is your budget currently for supplements?
Under $50
$50 - $100
$100 - $150
$150+
Are you interested in:
Trying free samples
Hearing about affordable starter packs
Learning more about the business side too
Just curious for now
What’s the best way to chat with you?
Text
Messenger
Instagram
Phone call
Thanks so much for filling this out!💓
I’ll take a look and message you with some options I think would be a great fit for you!
Submit
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