Wellness Survey
Thank you so much for taking a few minutes to fill out this survey! My hope is that by completing this there may be a way that I can serve you in your wellness goals!
Name
*
First Name
Last Name
Email
*
example@example.com
Instagram Handle (if applicable)
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Are you currently experiencing any of the following? Check all that apply.
Bloating
Digestive Issues
Low Energy/Fatigue
Anxiety
Brain Fog
Trouble Sleeping
Skin Issues
Weight loss
Weight gain
None of the above
Are you currently satisfied with the look/feel of your skin?
Yes
No
Could be Better
Are you experiencing any of these skin issues? Check all that apply.
Acne
Oily Skin
Dry Skin
Signs of Aging
Fine lines/Wrinkles
Dark Spots/Age Spots/Post Acne Scars
Dull Skin/Uneven Skin Tone
None of the above
Are you familiar with ingredients in wellness and beauty products and how they can affect your overall health?
I'm familiar, but haven't thought about looking into it
I'm somewhat familiar, but could use some more info
I'm an avid label reader and into low-tox living
I'm not familiar with how ingredients affect my overall health
Are you familiar with gut health and how this can affect your overall health, your skin and your mental health?
I'm familiar but could use more info
Yes! I'm a gut health enthusiast
No
I want to help you! How can I best follow up?! Check all that apply.
Product recommendations for overall wellness
Personalized product recommendations based on your answers above
Let's chat!
What areas of your life would you want to improve?
Overall Wellness
More Community/Friendships
Extra Income
Mindset/Mental Health
Submit
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