Robin's Wellness Assessment

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Take a moment to reflect on your wellness. Mark the option that best describes you.

Name *

Cell Number *

Email *

Preferred way to contact you? *

Text

Have you used Xyngular in the past? *

Yes

Maybe

If yes who did you work with?

Energy
Choose the one that best describes you *

I wake up refreshed and stay energized throughout the day.

I feel tired mid-day or rely on caffeine to keep going.

I often feel drained and struggle to stay awake.

Required

Sleep
Choose the one that best describes you *

I sleep 7–9 hours and wake up feeling rested.

I sleep 5–6 hours and feel okay most days.

I struggle with sleep or feel tired most mornings.

Required

Digestion
Choose the one that best describes you *

My digestion feels smooth, and I’m regular.

I have occasional discomfort or irregularity.

I frequently feel bloated, gassy, or sluggish.

Required

Weight Management & Metabolism
Choose the one that best describes you *

I maintain a healthy weight and feel in control of my metabolism.

I struggle occasionally with weight or metabolism issues.

I feel stuck or frustrated with my weight and metabolism.

Required

Stress & Emotions
Choose the one that best describes you *

I feel balanced and manage stress well.

I feel neutral or slightly stressed.

I feel overwhelmed or emotionally drained.

Required

Hormones
Choose the one that best describes you *

I feel balanced and in tune with my body.

I experience occasional imbalances (e.g., mood swings, low energy).

I often feel out of sync (e.g., irregular cycles, chronic fatigue, or hormonal issues).

Required

Movement
Choose the one that best describes you *

I move my body daily and feel strong.

I move occasionally but not consistently.

I rarely move and feel stiff or weak.

Required

By what date you need to see changes? *

Are you interested on having a personal consultation? *

Not all

Yes Please! Help me out!

How much are you willing to invest in your wellness? *

ZERO

$50

$150

$250

$350

$450+

UNLIMITED

Monthly

Need Help Paying

Would like to earn an extra

Anything else I should know about you?

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