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Wellness Assessment
Midlife Metabolism Reset
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First name
Last name
Email
Phone
How much do you know about carotenoid antioxidants?
Not much
Some
Alot
What is your #1 health concern right now?
Additional concerns or areas you want to improve:
Overall Health
Bloating or digestive issues
Premature Aging
Stress
Energy Levels
Hormones
Brain Health
Sleep Quality
Weight
Blood Sugar
Inflammation
Bone & Joint Health
Vision/Eye Health
Heart Health
Periodontal Health
Immune Function
Other
List your top 3 of the above
How many servings of fresh fruits + veggies do you eat per day?
1-2
3-5
6-9
10+
Do you currently take supplements?
If so, are they working?
Yes
Not Sure
No
How much are you willing to invest in your health per day?
$1
$3
$5
$10
On a scale of 1–10, how motivated are you to improve your health + energy?
Do you workout or move your body regularly?
Not yet
1-2x/week
3-5x/week
6-7x/week
Do you smoke or vape?
Never
Daily
Weekly
How many hours a night do you avg of sleep?
3-5 hours
6-8 hours
9+
Do you currently take a collagen supplement?
No
Yes
Have you ever had your nutritional wellness (Prysm) score tested?
Yes
No
Not Sure
Please enter your Prysm health score here if you know it.
Submit
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