Wellness Survey
EMBODIED WITH ERICA
Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
IG Handle
Are you currently experiencing any of the following? Check all that apply.
Bloating
Digestive Issues
Low Energy/Fatigue
Autoimmune Disorders
Anxiety
Brain Fog
Trouble Sleeping
Perimenopause/Menopausal
Menstrual Discomfort
Frequent UTIs
Are you currently satisfied with your skin/skincare routine?
Yes
Could be better
No
Are you currently experiencing any of the following common skin issues?
Acne
Eczema
Oily Skin
Dry Skin
Fine Lines/Wrinkles
Signs of Aging
Dark Spots/Age Spots
Dull Skin
Are you familiar with ingredients in wellness/beauty products and how these can affect overall health?
I'm familiar but don't really care
I'm somewhat familiar but could use some info
I'm an avid label reader & all about a low tox life
I'm not familiar but willing to learn
Are you familiar with gut health and how it can affect your overall health, skin, & mental health?
I'm familiar but would love to learn more
Yes! Gut Health Enthusiast
No but I'm open to learning
Not really interested
I want to help you in any way I can! How can I best follow up?! Check all that apply.
Product recs for skin and overall wellness
Add me to your VIP Facebook Group to stay in the loop
I'm interested in group challenges
What areas of your life do you want to improve? Check all that apply.
Overall wellness
More community/friendships
More income/financial stability
Mindset/Mental Health
Are you a mama?
Yes
No
Currently expecting!
If you have young children/are expecting, are you currently breastfeeding?
Yes
No
I plan to
Are you open to hopping on a quick 15 min consultation call to discuss your survey?
Yes
Not at this time
Submit
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