Health & Wellness Survey
Full Name
First Name
Last Name
E-mail
example@example.com
1. What do you consider your biggest health and wellness challenge is right now? Choose all that apply.
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Chronic Pain
Low Energy
Mood Swings
Anxiety
Losing Weight
Time Management
Can't Focus, Scattered Attention
Sugar Addiction
Endless Cravings
Digestive Issues
Insomnia
Emotional Eating
Brain Fog
Low Immune system
Other
2. What do you feel is the biggest obstacle holding you back from overcoming your pain points? Choose all that apply.
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Time
Burned out, Overwhelm
No support from friends or family
No support from a wellness or health professional
Too much conflicting information out there and don't know where to begin
Tried before and failed so afraid to attempt it again
Don't know what to eat or cook, need recipes
Know what to do, but hard to implement into daily routine
Other
3. What are your favorite ways to learn when it comes to your health and wellness? Choose all that apply.
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Written text (PDFs, books, manuals, etc.)
Video
Audio
Group coaching
One on one coaching
Virtual webinars
Live in-person workshops or events
Facebook Groups
Other
4. What are you interested in learning? Choose all that apply.
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How to build your immune system
How to quit sugar
How to plan healthier meals/recipes/shopping lists
How to have a happy healthy gut
How to improve mindset/mental wellness
How to curb emotional eating/end cravings
How to make healthy habits stick
Tips/Tricks for self-massage and tools
Virtual Fitness Programs you can do at home
How to lose weight and keep it off
How to eat healthy on a low budget
How to make healthier meals the whole family will enjoy
Tips for kids wellness and kid friendly recipes
How to use Essential Oils
Time-saving healthy tips for busy people
How to go Gluten Free
How to go Dairy Free
How to go Vegetarian or Vegan
Other
5. What is your biggest frustration or fear when it comes to your health and wellness goals? I want to know! If you chose “other” in the answers above, you can also elaborate on those in this section.
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6. Would you like to schedule a 30-minute Wellness Coaching Session with me (at no cost to you) to ask you more questions about your health and wellness challenges? I’ll also allow time at the end of our call to help you find one easy solution you can implement to help you with your health and wellness challenges. This complimentary session is limited to the first 10 people who complete the survey.
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Yes
No
If you replied yes to the above question, please let us know best time to reach you and your phone number.
Phone Number
Format: (000) 000-0000.
Submit
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