Part 1: Getting to Know YOU Better!
Please know this information is shared directly with us and will not be shared anywhere else. Make your way through and answer to the best of your ability,. Help US, so that we may help YOU! :)
Name
*
First Name
Last Name
Email
*
example@example.com
How did you connect with us?
*
Please Select
Met Holly
Met Michele
Met Dawn
Met Rhiannon
Met Shannyn
Met Marilou
Met Jackie
Met Jenny
Met Sam
Met Linda
Met Alisa
Met HeatherZ
Met Lynne
Met Other Team Partner
Referral
Business card
In person seminar/vendor event/health fair
Online seminar/health talk/opportunity event
Facebook post/reel
Instagram post/reel
LinkedIN
If Referred, by who?
Best Phone to Reach you Regarding Your Answers
*
Please enter a valid phone number.
Your Age (or the age of the person of inquiry)
*
12 or under
12-17
18-25
25-35
35-45
45-55
55-65
65-75
76 or over
Part 2: Health Overview
Regarding your health the last 6-12 months, please share some of your struggles or impairments
Regarding your health, check all that apply
Sleep Issues
Mood Issues
Stress Struggles
Anxiousness
Sadness
Pain Issues
Gut or Digestive Issues
Lack Energy
Lack Focus
Thin hair, skin or nails, wrinkles/fine lines
Immune Health Stuggles
Allergies
How would you rate your overall health?
1
2
3
4
5
ugh, help-----------------very Healthy
How high are your stress levels?
1
2
3
4
5
no worries---------------stressed out
How many hours of sleep do you average nightly?
Part 2: Health Overview Continued
What best describes you?
Health Conscious- "we have one body, one life"
I try to be healthy- "everything in moderation"
I see food & eat it- "too rushed to eat healthy"
If I had more time & money I'd eat better
Let's chat movement! Choose the best 1-2 answers that apply.
I exercise daily, I maintain flexibility
I try to exercise 3-5 times a week
I move my body 2-3 times a week
I want to move and gain flexibility
I have pain that slows me down
I rarely move, not flexible at all
Have you ever tried CBD?
Please Select
Yes, and loved
Yes, did not work
Yes, but I would love better coaching from you
Not yet, Help me get started please!
What is CBD?
Do you have trouble staying hydrated?
No, I drink tons of water
Sometimes, I should probably drink more
Always, constant struggle
Part 2: Health Overview Continued
You and your pets
Are you taking any medications for:
Diabetes
Thyroid
Blood Pressure
Mood
High Cholesterol
Coumadin
Other
Indicate the TOP health item you would like to seek support on and the average number of YEARS you have struggled with the issue.
ex. poor sleep, 25 years,,, or pain left leg, 10 years
Do you have a pet with any of these issues?
*
Sick/nervous with travel, grooming or strangers
Skittish, Pacing, or excessive licking behaviors
Slowing, difficulty climbing stairs,, pain
Poor appetite
Behavior problems or excessive barking
Aggression
I do not have pets
Part 3: ALMOST DONE! :)
Have you ever considered partnering in the hemp based wellness space?
*
No
Not really, but I would be open to more information
Not in the past, but I am in the holistic wellness space and would be open to integrating
Yes, especially if it means it would help cover my cost of personal product use
Yes, I just do not know how to choose the right company
Please use this space to free text anything you wish to expand on for you, your health, CBD experience, or any pet issues.
How ready are you to up level your health and wellness?
I have never been more ready!
I want to but know I need support
I am scared, not sure if I am ready just yet
Submit
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