HEALTH INVENTORY
Completing this survey will help me understand your health goals and know which products to recommend. This is not a purchase or a commitment.
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Gender
Male
Female
Age
*
18-25
26-34
35-44
45-54
55-64
65+
Overall quality of:
Rows
4 Very Good
3 Good
2 Neutral
1 Bad
Weight/Body Composition
Chronic Pain
Mental Clarity/Focus
Digestion
Skin Health (Lines, Wrinkles, Dark Circles, Uneven Tone, Redness, Acne,Rosacea,Eczema,etc.)
Weight
Additional Health Issues:
Difficulty reaching/maintaining healthy weight
IBS/Digestive Irritability
GERD/Acid Reflux
Anxiety
Headaches/Migraines
Allergies (Seasonal and/or Food)
Frequently sick
Thyroid Issues
Skin Issues
Hormonal changes/Cortisol/Perio-Menopausal
Other
Have you been diagnosed as a Diabetic?
If not, do you have any issues with blood sugar stability?
What's 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 body fat composition?
*
Fit
Feel Healthy but can benefit from losing 1-9 lbs
Desire to lose 10-15 lbs
Desire to lose 16+ lbs
How would you rate your stress levels
Not stressed
Somewhat stressed
Very stressed
How many hours a night do you sleep?
8-10
6-8
Less than 6
How would you rate your daily bowel movements?
*
Non-existent
A few times a week
At least once a day
A few times a day
How long have you had an issue with regularity?
Have you been diagnosed with any health conditions?
Your current diet could be best characterized as:
low-fat
low-carb
high-protein
Vegetarian/Vegan
No special diet
What solution do you need the most regarding your health goals?
*
Gut Health-better digestion or regularity
Weight Loss
Better Sleep
Better Skin, Hair Nails
Better Digestion
Better Immune Health
General Nutrition-Daily Vitamins/Supplements Nutrition
More mobility
Better concentration & focus
Other
My preferred drink flavor of choice would be:
Raspberry Lemon Watermelon
Black Cherry Lime Blossom
Sweet Tea
Blood Orange (only in the case of weight loss)
What price range do you typically consider when investing in health and wellness products?
$100-$150
$150-$200
$200-$250
On a scale of 1-10, how committed are you to see true change, not just a quick fix?
*
1
2
3
4
5
6
7
8
9
10
TImeline for achieving your goal.
Rows
8 WKS
16 WKS
24 WKS
32 WKS
40 WKS
1 YEAR
NOW
Do you currently use any supplements? If yes please list which ones under is there anything else you want me to know.
Yes
No
Is there anything else you'd like me to know?
Are you currently working with a Plexus Ambassador?
*
Yes
No
Have you ever worked with a Plexus Ambassador?
*
Yes
No
What is the best way to follow up with you?
Text Message
Phone Call
Email
Instagram Messenger
Facebook Messenger
Submit
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