Form
Name
First Name
Last Name
IG handle and/or Facebook name (ex: @yinfinityandbeyond / Yin Agbontaen)
Email
example@example.com
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/stomach discomfort/digestive issues
brain fog/low energy/fatigue
poor sleep
heavy cramping / pain during period
low mood/unexplained mood swings
neurodivergence (ex: ADHD/ADD)
hormonal acne or other skin concerns
none of the above
What is your current lifestyle?
work full time and/or part time jobs
hardly any free time! (travel, social butterfly, hobbies, work, etc)
soft girl life!
Do you currently workout? If so, what is your routine + body goal? If not, please do state a body goal if you have one and/or what's holding you back (consistency, time, not knowing what to do, etc).
Describe your current diet. Check all that apply.
I cook at home most days
I eat out A LOT
I don't pay attention to food that much
I eat when I can
I snack a lot
I'm great about eating + eating nutritiously
How would you describe yourself in life currently?
Absolutely thriving
Life is good, could be better
I'm ok where I'm at but I know I'm made for more
I'm down bad
In your ideal world, what would you like to have? Check all that apply
a better understanding of my body
glowing, clear skin
better energy/high productivity
more money and travel
sustainable healthy habits that I enjoy
a career I adore
a supportive community
a body that looks as good as it feels
work/life flow that feels good
What resources do you enjoy having to support the responses you've given?
i'd love to be part of an accountability group!
link and discounts to beauty + wellness product recommendations
info on earning an income and brand trips
all of the above
Scale of 1-5, how important is it that you address/fix any issues you checked off?
Please Select
1 - not a huge focus but it's on my mind
2
3
4
5- give me the solutions and I'm doing it!
How would you like me to respond to your survey?
IG dm
text and/or phone call
Submit
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