Full Name *

Email *

Cell Phone Number *

for text encouragements or updates

Are you a Plexus Ambassador or VIP Customer? *

Yes

Your Goals

What are your biggest health goals right now? *

More energy

Better digestion / less bloating

Fewer cravings / more balanced appetite

Weight Loss

Better mood or focus

Clearer skin

Other

If "Other" please explain.

Your Current Challenges

Which of these sound like you? (check all that apply) *

I crash around 2–3 PM

I rely on caffeine or sugar to get through the day

I feel bloated, gassy, or irregular

I struggle with mood swings or irritability

I have a hard time sleeping or staying asleep

I can’t seem to lose weight no matter what I try

My skin or hormones feel “off”

Your Current Symptoms

Gut Health Checklist (check all that apply) *

Bloating

Low energy

Sugar cravings

Headaches

Constipation

PMS

Mood swings

Hormonal changes

Skin issues

Your Current Habits

Do you eat enough protein? *

Yes
No
Not sure
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List is empty.

Do you overeat sugar? *

Yes
Often
Sometimes
Not usually
Hardly ever
No elements found. Consider changing the search query.
List is empty.

Do you eat vegetables and fruit every day? *

Every day
Most days
A few times a week
Not usually
No elements found. Consider changing the search query.
List is empty.

How would you describe your eating habits? *

How many days per week do you exercise at least 30 minutes? *

Usually none

1-3

4-7

What’s your typical choice of exercise? *

Do you currently take any medications? (If yes, please list) *

Do you currently take any supplements? (If yes, please list) *

Your Faith & Motivation

What motivates you to take care of your health right now? *

Is there a specific area of your life you feel God is calling you to be more disciplined or intentional with your health? *

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