Design a Healthy Life - Breakthrough Session Survey

Let’s talk about your Gut!

I’m so excited that you’re here!

Having a space to talk & get clear about your symptoms & how they might be impacting your life is an important first step in healing your digestion.

At the end of the Survey, you’ll have an opportunity to schedule a complimentary Breakthrough Session & speak to me personally about your concerns. All answers are confidential.
Name
Email Address*
Phone Number

Area CodePhone Number
1. Tell me a little bit about your story. What compels you to complete this Survey?
2. What’s your biggest struggle with digestion and your overall health?
Heartburn or acid refluxFeeling gassy & bloatedCramps or stomachache after eatingBelchingDiarrhea or constipationNauseaChronic indigestionIntense sugar cravings
3b. Do you know if it’s linked to specific foods? Have you spent any time looking at food triggers?

4a. On a scale of 1-10 (10 being highest), how important is it to you to get this problem solved?

	1	2	3	4	5	6	7	8	9	10

1 is Not important, 10 is Very Important

4b. Why is that important to you?
5. What is the #1 obstacle that’s kept you from solving these problems in the past?
6. Where would you like your health to be in 6 months? 12 months? What would a Home Run look like for you?
I can’t wait to chat with you on the other side!
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