Health & Vitality Questionnaire

Welcome

Your Health & Wellness is IMPORTANT! So before I attempt to work with you or offer solutions for your health needs, I prefer to get to know you & make sure you're a fit so I don't waste your time!

Please honestly answer this BRIEF survey, and if approved, you can book your 5-15 min session with me!

I can't wait to help you reach your wellness goals!

Let's get a few contact details first...

First Name *

Last Name *

Your Best Email *

Please describe for me your current health challenges and how long you have had each of these challenges. *

What have you already tried / purchased / done to solve these issues? *

On a scale of 1 to 10 (10 being very high) what is your typical level of stress on a daily basis.

Do you take any medications, and if so, which ones? *

Do you take any supplements regularly *

Yes, daily

On occasion

No, not at all

When I find you some solutions that improve your health, would you want to learn how to be compensated for your testimonial? *

Yes

Is there anything else you'd like to share as to why you should be approved to work with us? *