Do you feel healthy? *

Yes

I think so

Kind of

No

I don't know

What do you do everyday to make yourself healthier? *

Drink clean water

Exercise

Avoid sugar

Avoid processed foods

Balance protein, fat, and carbs

Get sunlight

Prioritize sleep

Spend time in nature

Practice de-stressing techniques

Healthy work/family balance

Other...

Have you tried "fad" diets? Did they work? *

Yes and yes!

Yes and no :(

No

What health issue(s) come to your mind when you consider working with me? *

Fatigue

Weight loss/weight gain

High cholesterol

Infertility

Adrenal fatigue

Autoimmune disease

Sinus issues/congestion/chronic cough

Abdominal pain

Ulcers

Bloating/swelling

Nausea/vomiting

Constipation/diarrhea

Heart burn

High blood pressure

Urinary issues

Cancer/family history of cancer

Anxiety/depression/mood swings

Difficulty sleeping

Headaches/migraines

Joint pain

Allergies

Food sensitivities

Abnormal/painful periods

Hormonal issues

Hair loss

PCOS

Endometriosis

Osteoporosis

Pregnancy/postpartum

Neuropathy

Skin issues/rashes/acne/itchy

Vitamin deficiencies

Medication side-affects

Would you say your health affects your life? *

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Name *

First Name

Last Name

Would you like to be contacted for a free 15 minute health assessment call? *

Yes, please!

No, thanks!

If yes, please provide your phone number

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