HEMP WELLNESS ASSESSMENT
Kelly Cipriani
Educator & Wellness Advocate
Is CBD right for you?
Let’s discover how you can feel your best!
Name
Full Name
Last Name
(000) 000-0000
Format: (000) 000-0000.
Email
example@example.com
What is the best way to connect?
Call
Text
Email
Have you tried CBD?
Yes, I tried it in the past
Yes, I currently take it
No, but I’m curious
If you have tried CBD, did you achieve the results you expected?
Yes
No
If you answered yes, did you have guidance with which products are right for you and how to dose properly?
Yes
No
What are your main health concerns?
Sleep
Pain, inflammation
Gut health
Anxiousness, stress, feeling overwhelmed
Signs of aging, hair loss
Skin disorders, general skin irritation
Do you have a pet that gets nervous during storms, car rides, vet visits, fireworks, etc?
Yes
No
Do you know a child who has trouble with focus or staying organized and calm during the school day or otherwise?
Yes
No
Please share any additional concerns about your health or someone you care about.
If you were referred to me, who can I thank?
KellysLocalCBD.com
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