Jenny's 2 Minute Wellness Quiz

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

I'd love to know your wellness goals!

Curious if any of our clean label wellness products might be right for you? Fill this out and I will send you a customized suggestion of products that can help with your goals

Name: *

Phone Number: *

Email: *

What are your primary health goals? (check all that apply) *

Weight Management/Body Composition

Anti-Aging (Skin, Hair, Nails, Joints)

Nutrition & Gut Health

Non-toxic Home & Personal Care

All Of The Above

Required

How is your energy and sleep (check all that apply) *

I could use some help with energy

I could use some help with sleep

I am great with both and don't need help

Required

How many servings of fruits and vegetables do you consume on average each day. A serving is the size of your fist. *

0-3

4-6

7 or more

Do you experience digestion issues (bloating, constipation or diarrhea)? *

Often

Sometimes

Rarely

Never

Do you experience joint discomfort? *

Often

Sometimes

Rarely

Never

Which best describes how you feel about your current weight. *

I am happy with my current weight and body composition

I would like to lose weight and increase lean muscle

I would like to gain weight and increase lean muscle

I am happy with my weight but would like to improve lean muscle mass

Which best describes your skin. Check all that apply. *

I am happy with the look and feel of my skin

I would like younger looking skin, less wrinkles & fine lines

I would like to improve my skin’s hydration, firmness, and elasticity

Required

How would you describe your focus and attention? *

I am very focused

I get distracted sometimes

How are you with caffeine? *

I can drink it all day

I can have a little

I am very sensitive to caffeine

Do you use a sunless tanner or spray tan? *

Not currently

Yes

I'd like to!

Any other health goals you'd like to share? Anything you are struggling with or are working on? *

Which Modere products do you currently use?

What product categories would you be open to replacing with Modere Clean Living Products if they were superior products at a better price point? *

Home Products (ex: detergent, dish soap, multi-surface cleaner)

Personal Care (ex: deodorant, handwash, shower gel, shampoo/conditioner)

Not at this time.

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms