Survey

Please Complete the Following Questions

Name*

Email Address*

Phone*

Please rate the following from 1-10 (1 having 10 being unbearable/having a large impact on your health or goals):

Physical Pain

Stomach aches or digestive complaints

Quality of Sleep

Clarity of Mind

Positivity mindset

Energy Level

Overall Well-being

Circumstances

In relation to your goals, what level of satisfaction are you currently? Please explain: *

Please rate the following from 1-10 (1 being very unsatisfied, 10 being very satisfied)

Choose the option that best describes you

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