Wellness Questionnaire
I offer products to those in the 15 Countries listed at the bottom.
Name
*
First Name
Last Name
Email
*
example: holisticmindfulmom@gmail.com
What is your Instagram handle?
*
example: @mindfulmomholistics *follow me :)
Phone Number
*
-
Country Code
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Area Code
Phone Number
Do you struggle with any of the following?
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Feeling anxious or overwhelmed
Irritability or mood swings
Feeling hormonal chaos, like crying over nothing or anger /rage
Known thyroid Imbalance/Autoimmune
Lime Disease/Mold Toxicity/Heavy Metals Overload
Brain fog or forgetfullness
Constant fatigue or low energy
Relying on caffeine or sugar (or 3pm nap) to get through the day
Trouble falling asleep or staying asleep
Waking up groggy or unrested
Trouble focusing or staying mentally sharp
Irregular periods or intense PMS
Postpartum hormone imbalance
Perimenopause of menopausal symptoms
Frequent colds or slow recovery after illness
Bloating, constipation, sluggish digestion
Skin issues like acne or dullness
Premature aging signs like sagging skin and wrinkles
Muscle or joint aches
Chronic inflammation or pain
Feeling "off" despite a healthy lifestyle
"Normal" blood test results despite still feeling foggy, tired, of "off"
Can't lose weight no matter how hard you try
Hair loss
Known cortisol spikes / out of the blue anxiety
Chronic stress / high cortisol
Trouble feeling or staying calm, a sense of overall grounding
What are your top 2-3 symptoms you want to address?
*
What are your short & long term health goals? What supplements are you currently taking ? What else are you doing to help with your goals? Do you exercise, even lightly (i.e take walks)? Tell me anything you think I need to know!
What is your stress level? 1= not at all stressed, 10= always very stressed
How many hours of sleep do you get on the average night?
How are you currently trying to find calm, energy & healing:
I am too anxious, exhausted and foggy to begin
I have tried, nothing works
I have some tools and they have helped some!
I'm doing good overall, just need more healing
Please confirm your country of residence.
*
USA
Canada
Mexico
UK
Germany
Australia
Canada
France
Greece
Guam
Netherlands
New Zealand
Poland
Puerto Rico
Spain
Sweeden
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