Health and Wellness Survey

Health & Wellness Survey
Full Name
First NameLast Name
E-mail
example@example.com
1. What do you consider your biggest health and wellness challenge is right now? Choose all that apply.*
Chronic PainLow EnergyMood SwingsAnxietyLosing WeightTime ManagementCan't Focus, Scattered AttentionSugar AddictionEndless CravingsDigestive IssuesInsomniaEmotional EatingBrain FogLow Immune systemOther
2. What do you feel is the biggest obstacle holding you back from overcoming your pain points? Choose all that apply.*
TimeBurned out, OverwhelmNo support from friends or familyNo support from a wellness or health professionalToo much conflicting information out there and don't know where to beginTried before and failed so afraid to attempt it againDon't know what to eat or cook, need recipesKnow what to do, but hard to implement into daily routineOther
3. What are your favorite ways to learn when it comes to your health and wellness? Choose all that apply.*
Written text (PDFs, books, manuals, etc.)VideoAudioGroup coachingOne on one coachingVirtual webinarsLive in-person workshops or eventsFacebook GroupsOther
4. What are you interested in learning? Choose all that apply.*
How to build your immune systemHow to quit sugarHow to plan healthier meals/recipes/shopping listsHow to have a happy healthy gutHow to improve mindset/mental wellnessHow to curb emotional eating/end cravingsHow to make healthy habits stickTips/Tricks for self-massage and toolsVirtual Fitness Programs you can do at homeHow to lose weight and keep it offHow to eat healthy on a low budgetHow to make healthier meals the whole family will enjoyTips for kids wellness and kid friendly recipesHow to use Essential OilsTime-saving healthy tips for busy peopleHow to go Gluten FreeHow to go Dairy FreeHow to go Vegetarian or VeganOther
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. *
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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If you replied yes to the above question, please let us know best time to reach you and your phone number.
Phone Number
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Health & Wellness Survey