Laura Horsch
Welcome to your personalized wellness assessment. I’m so glad you’re here! Whether you’re hoping for more energy, better sleep, balanced hormones, digestive support, or simply want to feel like yourself again, you’ve taken an important first step. This assessment helps me understand your goals, lifestyle, and current health so I can offer personalized recommendations. It takes about 8–10 minutes, and there are no right or wrong answers.
Let’s Get to Know You
We’ll start with a few basics so the rest of your answers can feel more personal and relevant.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Age
*
Gender
Male
Female
Prefer not to say
Your Health Goals
This section helps me understand what you’d most like to improve so I can support those priorities.
What are the top three things you'd love to improve about your health?
If we were celebrating your health six months from now, what would you hope had changed?
Energy
Weight management
Digestion
Detox/cleanse
Hormonal balance
Mental clarity
Immune support
Sleep
Skin health
Muscle building
General wellness
Other
If your health were exactly where you wanted it to be six months from now, what would that allow you to do, enjoy, or experience that you can't today?
How You're Feeling Today
A quick snapshot of how you’re feeling right now helps paint a clearer picture of your current wellness.
How would you describe your current health status?
*
Excellent
Good
Average
Below average
Poor
How would you describe your energy most days?
Very low
Low
Moderate
High
How many hours of sleep do you get on average per night?
How well are you sleeping lately?
Poor
Fair
Good
Excellent
Heading
How often do you exercise?
Never
1-2x/week
3-4x/week
5+/week
Body Signals & Symptoms
Here you can share any signals or symptoms your body has been giving you lately.
Which of these body signals or symptoms have you been experiencing recently? (Select all that apply.)
Bloating
Constipation
Gas
Loose bowels
Acid reflux
Fatigue
Brain Fog
Sugar cravings
Weight gain
Water retention/puffiness
Joint discomfort
Poor sleep
Skin issues
Hormonal imbalance
Frequent illness
Headaches
Midday energy crashes
Difficulty concentrating
Memory lapses/forgetfulness
Feeling unmotivated or sluggish
Bad breath or body odor
Sensitivity to smells/chemicals
Frequent nighttime urination
Dark or strong-smelling urine
Mood swings
Low libido
Cold hands and feet
Tingling or numbness
Body discomfort/pain
Skin/hair, aging concerns
Your Health History
A little background goes a long way in helping me better understand your overall health picture.
Have you been diagnosed with any medical conditions you'd like me to know about?
Are you currently taking any supplements or medications? (Feel free to list here.)
Do you have any allergies or sensitivities that we should be aware of?
Nutrition & Daily Habits
Your everyday routines can reveal a lot about what’s supporting you and what may need a little extra care.
How would you describe your current eating habits?
Poor
Average
Good
Very healthy
On average, how much water do you drink each day?
Low
Moderate
High
Do you consume: (check all that apply)
Coffee
Alcohol
Sugar frequently
Processed foods
Detox & Internal Wellness
This section explores how your body may be processing and clearing out what it doesn’t need.
Have you ever done a detox or cleanse before?
Yes
No
Do you feel your body could benefit from additional detox support?
Yes
No
Not sure
Quantum Bioscan Results (Optional)
If you have scan results, they can offer an extra layer of insight — but this step is completely optional.
Have you been assessed through a Quantum Bioscan?
Yes
No
No, but I would like to get scanned.
Upload your scan results here, if you have them (optional):
Browse Files
Drag and drop files here
Choose a file
Optional — you can skip this if you don't have scan results.
Cancel
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Creating a plan that works for you. I believe the best wellness plan is one you'll actually be able to follow. These next few questions simply help me recommend solutions that fit your goals, your lifestyle, and your budget. There are no right or wrong answers.
Creating Your Personalized Plan
These questions help gauge what feels realistic and supportive for you moving forward.
About how much do you currently invest in your health each month (supplements, vitamins, wellness products, etc.)?
$0-50
$50-100
$100-200
$200+
What monthly wellness investment feels comfortable for you right now?
$50-100
$100-200
$200-300
$300+
When would you like to do something about your health?
Now!
Next week
Next month
In the next 6 months
Other
Next Steps
We’re almost done — this final section helps guide the best next step for your wellness journey.
Would you like to learn about optional membership savings that can help lower the cost of your wellness products?
Yes
No
Tell me more!
Which of the following would you be interested in learning more about?
Getting products at wholesale pricing (20-40% off)
Earning loyalty credits/free products
Referring friends & earning monetary rewards
Starting a wellness business of your own
Using the Bioscanner for personal or business use
Retailing products to stock and sell in a store, clinic or wellness center
Adding products to your virtual or online store
Personalized Wellness Options
I’ll begin with personalized recommendations based on your responses, and only explore savings, referrals, or business options if that’s something you’re interested in.
How would you prefer I follow up with you?
Phone Call
Zoom Meeting
Text Message
Email
I'll let you decide what's best.
On a scale of 1–10, how committed are you to making changes to improve your health right now?
1 = Just gathering information
3 = Curious but not quite ready
5 = Ready to make a few small changes
7 = I'm committed and ready to get started
10 = I'm all in and excited to transform my health!
Would you like me to pray for you as I prepare your wellness recommendations?
Yes, I'd appreciate that.
No thank you.
What is one thing you're already doing well for your health that you're proud of?
Is there anything else you'd like me to know about your health, your goals, or how I can best support you?
Consent & Disclaimer:
• I understand these products are designed to support overall wellness and are not intended to diagnose, treat, cure, or prevent any disease. • I understand my answers to this survey are confidential and only being shared to the person helping with my assessment and not being shared directly with the company or other representatives. • I agree to be contacted with my personalized wellness plan and product recommendations.
Signature
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Thank you for trusting me with your story. Every response is kept confidential and reviewed personally so I can create recommendations tailored specifically to you.
Submit My Wellness Blueprint
Submit My Wellness Blueprint
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