Reverse Aging Pre-Survey
This survey is designed to gather health and wellness data on individuals who are looking to age well. People who participate in this survey will have the option to receive information and product samples.
1.
Who invited you to the survey?
2.
What is your age?
Under 39
40-49
50-59
60-69
70-79
80+
3.
What is your gender?
Female
Male
4.
What is your ethnic background?
Black or African American
Asian
Middle Eastern or North African
Caucasian
Hispanic or Latino
American Indian / Alaska Native
Native Hawaiian or other Pacific Islander
5.
What is current activity level?
Sedentary - less than 3000 steps a day
Minimally active - 3 days or less a week of activity for at least 20 min.
Active - 3-5 days a week of activity for at least 45 min.
Very active - 5 or more days a week for at least 1 hour
6.
What is your current level of sleep?
Great sleep
Sleeping but not rested
Waking up throughout the night
Poor sleep
7.
What is your current level of energy?
High Energy
Medium Energy
Low Energy
8.
What do you think of when you hear reverse aging?
Check all that apply.
Less joint pain
Better weight control
Better memory recall
Mental clarity
Improved eyesight
Better sleep
Better mobility/balance
9.
What do you wish you could change most regarding aging?
Check your top 3.
Excessive weight-gain
Stubborn belly fat
Joint pain
Inflammation
Poor eyesight/focusing
Poor sleep
Bladder control
Lack of short-term memory
Lack of flexibility/mobility
Poor Health: cholesterol, blood pressure, A1C
10.
If 2 of the above issues could be improved or possibly resolved, would you commit to 60 days on a revolutionary reverse aging product?
Yes
No
11.
If "Yes", Please provide a phone number for next steps.