Wellness Survey
Please note to complete all fields followed by an asterisk.
First Name*
Last Name*
E-mail Address*
Home Phone*
Street Address
City
State
Zip/Postal Code
Country
Height*
Weight*
Age*
Which of these words best describes your own lifestyle*
Do you think that you get 100% of the daily nutrition needed for good health*
Do you experience a loss of vitality during the day*
Do you feel that you would like to lose weight*
If "Yes", How much weight?*
Would you like us to contact you*
If there were three things you could improve about your health what would they be?*
Do you take supplements (vitamins, minerals, protein, antioxidants)?*
What other programs/products have you tried in the past?*
I find it hard to make healthy diet choices*
I don’t think I eat enough fruits and vegetables*
I am concerned about the effect of the environment on my body*
I want my body to be nourished*
I have a very busy lifestyle*
I would like to be more active*
Do you have some health concerns?*
Is where you are with your health where you want to be?*
Is just treating symptoms the answer to wellness.*
Is doing this on and off again a way of making a long term commitment to your health.*
Take the wellness or weight management plans and see if you are satisfied? If not, get your money back!*
Do you think wellness might be a fad?*
If you answered yes to any of these questions, Mardale Wellness Group has options for you.
Step 1:Assess your wellness answers and design your health goals.
Step 2: Identify key areas you need impact to reach your lifestyle goals.
Step 3: Choose the Plan or action that you will commit to
Step 4: Contact the person who shared this brochure with you.
