30-Second Health Test

This survey is not for diagnostic or treatment purposes but as a preliminary assessment tool to support optimal wellness and help you find the best Wellness Program for YOU!

Name

Select your gender

Code

Phone

What is your primary goal?

How much weight do you want to lose? (if weight loss is your primary goal

Do you have any of the following indications?

Aching Joints

Less Than 2 Bowel Movements Daily

Difficulty Losing Weight

Poor Memory

Skin/Complexion Problems

Stressful Lifestyle

Slow Recovery from Illness

Don't Exercise Regularly

Recurrent Yeast/Fungal Infections

Other health concern not mentioned aboved

Are you willing to explore the benefits of a plant-based diet?

No

Yes

Email Address

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

optimalwellness83@gmail.com

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