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Free Vitality Assessment
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* Indicates required question
Name
*
Your answer
Phone number
Your answer
Email Address
*
Your answer
Have you received your FREE wellness gift from Peak?
*
Yes, and received the instruction email on uses
Yes, but I did not get a follow up email
No, please follow up about that
Do you currently use Essential Oils in any way? You'll be getting some in your welcome pack!!
Yes
No
I have in the past
Clear selection
*If you already have some oils in your home, please list the ones you have. This will help me lay out a routine in the simplest way with what you have.
Your answer
On a scale of 1-5 (5 being at it's best), how would you rate your physical fitness?
Definitely needs improvement
1
2
3
4
5
Never been better
Clear selection
On a scale of 1-5 (5 being at it's best), how would you rate your digestive health?
1
2
3
4
5
Clear selection
On a scale of 1-5 (5 being at it's best), how would you rate your mind & mood wellness?
1
2
3
4
5
Clear selection
On a scale of 1-5 (5 being at it's best), how would you rate your immune health?
1
2
3
4
5
Clear selection
On a scale of 1-5 (5 being at it's best), how would you rate your nutrition intake?
1
2
3
4
5
Clear selection
On a scale of 1-5 (5 being at it's best), how would you rate your sleep?
I struggle every night
1
2
3
4
5
I'm a log once I hit the pillow
Clear selection
On a scale of 1-5 (5 being at it's best), how would you rate your physical pain?
In constant pain
1
2
3
4
5
I barely ever have pain
Clear selection
How much water do you drink daily?
*
More than enough!
I have no idea how much I need, but I think I do ok
I barely get any in
How much time do you spend in your mindful practice? (reading, meditating, inspiring podcasts, journaling, breath work...etc)
*
I make time every day
When I remember and the stars align just right, I get a moment
Those moments don't exist for me
How much time do you spend on your physical movement practice?
*
I make time every day
When I remember and the stars align just right, I get a moment
Those moments don't exist for me
Tell me about your every day work routine.
*
I am always at a computer
I'm always on my feet
A healthy mix of sitting and standing
My job keeps me moving at all times
I spend many hours in bed after the sun rises
I wear heels all day
I wear supportive footwear all day
Required
If you could magically improve anything about your health & wellness right now, what would it be? Feel free to go into detail!
Your answer
Choose which areas of the body you need the most help with
Full Body
Neck
Shoulder
Upper back
Core
Elbow
Wrist
Low Back
Hip
IT Band
Knee
Shin
Achilles
Ankle & Foot
Other:
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