How is your health?
Thank you for participating in my survey. All responses are anonymous and not at all related to your email or social media accounts. Responses are completely anonymous. This data will be used purely by me to help provide better heath care solutions for people and will not be sold or provided to others.
I am developing my holistic health coaching practice and am creating packages that will best help people like you. I am searching for ways to make sure I will provide you with exactly the tools and support you need to live your life with confidence, energy and in good health!
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What is your gender?
What is your age?
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 or older
Do you have children?
What is your relationship status?
Please choose one. We don't judge, go you!
Loved up - in a relationship
It's complicated and messy
Dating and enjoying it
Going through a rough patch with my partner
What are your main health challenges right now?
Please pick your top 3.
Allergies, eczema or skin irritation
Bloating, digestive issues, reflux or irritable bowel syndrome
Weight loss or gain
Lack of energy, tiredness
Lack of support
Stress management or anxiety
Work life balance or time management
Acne or homones
Confused about healthy eating
What have you tried so far to help with your health issues?
Been to see my regular doctor
Visited a chiropractor or naturopath
Read books or magazines
Watched TV shows and/or movies
Visited websites and blogs
Purchased an online health program
Hired a personal traininer
Visited a heath food store
Gone to the gym
If you have used any websites to assist with your health concerns which sites were they?
What health products/services do you buy?
Vitamins or Supplements
Massage, Accupunture or Chiropractic
Yoga, pilates or gym classes
Diet books or programs
Packaged health foods
If you have read any books or magazines to assist with your health challenges, what did you read?
What are the top 3 values important to you right now?
Please pick 3
Ambition and career
My health and wellbeing
Wealth and abundance
Managing my finances
Detox or cleansing
Control of my life
How fully are you living in accordance with your values?
Not at all
If you could wave a magic wand and resolve one part of your life, which would it be, and why?
What is your biggest frustration that you would do anything to solve?
What is the main obstacle that has been in the way of achieving your health goals?
What motivates you the most?
Words of affirmation
Having a deadline
How much time do you spend on yourself in a typical week?
Your personal hobbies, interests and self care.
None at all
1 to 2 hours a week
2 to 4 hours a week
5 to 8 hours a week
More than 8 hours
How much money do you spend on yourself in a typical week?
On hobbies and fun, not on bills or essentials
up to $50
$51 to $100
$101 to $150
$151 to $200
What do you want most in Life?
Apart from world peace :-)
Would you be willing to participate in a further survey in future?
Yes - I will leave my email address below
No - thanks once was enough
Would you like an email to recieve a monthly newsletter?
Yes - Awesome I would love to have the news
No thanks I get too many emails
If you answered 'Yes' to either of the two questions above please fill out your name and email address below
Please let me know below if you have any other health concerns that you would like help to solve, anything you have not mentioned or any other suggestions about how I can help you with your health.
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