Quick Health Discovery
Completing this short survey will help us to address topics of interest in our webinar and we'll provide you with an early opportunity to schedule a free Wellness Discovery Call.
* Required
Email address
*
Your email
Full Name
*
Your answer
Phone Number
*
Your answer
What interested you in this presentation? (check all that apply)
*
Stress
Hormones
Belly Fat
Other
Required
"Other" interests for this webinar?
Your answer
What symptoms have you experienced? (check all that apply)
*
Weight gain
Anxiety/Depression
Fatigue
Hair loss
Low libido (sex drive)
High Blood Pressure
Pain
Moodiness
Sleep difficulties
Less interest to engage in what used to be your hobbies
Low self-esteem
Other _____________
Required
"Other Symptoms" you've experienced?
Your answer
What have you tried in the past?
Medications
Exercise
Diet
Other
What is your biggest motivation to resolve your health challenges?
Get off medications
To look and feel like myself again
Regain my zest for life
My children and/or grandchildren
What I am looking for in my health practitioner (check all that apply)
Uses a more natural approach
Looks to find the root cause of my health concerns
Has a personalized blue print for me
Holds me accountable to accomplish my health goals
Other_____________
"Other" things I'm looking for in a Health Practitioner
Your answer
Submit
Page 1 of 1
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
