To ensure you achieve your highest level of well-being, let's take the first step.
Email*
Valid email
What is concerning about your heart health? no concerns
*
Question
What is concerning about your heart health? no concerns
*
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Description
Loading image…
Caption
Long answer text
Length
Regular expression
Maximum character count
Minimum character count
Number
Custom error text
Answer key
(0 points)
Loading...
Loading…
What part of your overall health needs to improve but you are unsure how to start?
*
Question
What part of your overall health needs to improve but you are unsure how to start?
*
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Description
Loading image…
Caption
Weight management
Other…
Add option
or
add "Other"
…
Answer key
(0 points)
Loading...
Loading…
How ready are you to start making positive changes?
*
Question
How ready are you to start making positive changes?
*
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Description
Loading image…
Caption
I've already started
Other…
Add option
or
add "Other"
…
Answer key
(0 points)
Loading...
Loading…
What are your greatest barriers or challenges to make lifestyle changes for your health? going back to the sugar and junk
*
Question
What are your greatest barriers or challenges to make lifestyle changes for your health? going back to the sugar and junk
*
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Description
Loading image…
Caption
Short answer text
Response validation has been added.
Remove
Number
Text
Length
Regular expression
Greater than
Greater than or equal to
Less than
Less than or equal to
Equal to
Not equal to
Between
Not between
Is number
Whole number
Number
and
Number
Custom error text
Answer key
(0 points)
Loading...
Loading…
What are your goals and aspirations? weight loss, decreased headaches and heartburn, better skin and less hair loss
*
Question
What are your goals and aspirations? weight loss, decreased headaches and heartburn, better skin and less hair loss
*
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Description
Loading image…
Caption
Long answer text
Length
Regular expression
Maximum character count
Minimum character count
Number
Custom error text
Answer key
(0 points)
Loading...
Loading…
Link to Sheets
The number of responses collected by this form may exceed the limit supported by Sheets. If you're having trouble viewing your responses in Sheets, try downloading a .CSV instead.
Message for respondents
This form is no longer accepting responses
Summary
Question
Individual
Insights
Total points distribution
Loading...
Loading responses…
What is concerning about your heart health? no concerns
No responses yet for this question.
What part of your overall health needs to improve but you are unsure how to start?
Copy
No responses yet for this question.
How ready are you to start making positive changes?
Copy
No responses yet for this question.
What are your greatest barriers or challenges to make lifestyle changes for your health? going back to the sugar and junk
Copy
No responses yet for this question.
What are your goals and aspirations? weight loss, decreased headaches and heartburn, better skin and less hair loss
No responses yet for this question.
Waiting for responses
of
5
of
1
Loading...
Loading response…
Grades from previous versions of this form are hidden. Learn more
Settings
Release grades
Respondent settings
Global quiz defaults
Default question point value
Point values for every new question
points
Responses
Manage how responses are collected and protected
Collect email addresses
Required by Locked mode
Do not collect
Verified
Responder input
Send responders a copy of their response
Disabled by Locked mode
Requires Collect email addresses
Off
When requested
Always
Requires sign in
File upload
Total size limit for all uploaded files
This limit is smaller than the max size of a single response.
Responses will not be accepted after the limit is reached. Learn more