Zen From Within - Getting to Know You Survey

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* 1. This short survey allows us to get a snapshot of your needs and desires for Herbal/Nutrition services. Upon completion of the survey, you'll be able to schedule a 15 minute complimentary Strategy Session with Melita Mollohan, Holistic Health Practitioner to discuss our programs and help you determine how our unique approach to Holistic Health can best fit your needs.

If you are ready for a fully supported health transformation, please answer all questions below.

First and Last Name

pronouns: she/her, he/him, they/them

Email address (this is the email we will reach out to schedule your complimentary Strategy Session)

Phone number (this is the phone number we will call you at the time of your Strategy Session)

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* 2. We’d love to know where you are located. If you live within the US, in what state or territory do you live? And what city or town do you currently live in?

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* 3. We’d love to know how you specifically found me or who referred you. (Personal referral, video, live event, website, other and please be specific.)

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* 4. What are your main goals for seeking Holistic Health services with the Zen From Within Clinic? (Select all that apply)

Support with a specific health condition (ie: Crohn’s, Rheumatoid Arthritis, gas)

Lose some weight, increase energy or just a general sense of “I am not feeling as good as I could.”

I have been chronically ill for a long time and no one has been able to help me feel better.

I was referred by another practitioner (please let us know who in the space below).

Other (please specify)

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* 5. Do you have any known health or medical conditions or diagnosis that we should know about in helping you to find the best care? If yes, please explain.

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* 6. What have you tried so far to address your goal? (Diets, testing, modalities, etc.)

Not much, just getting started.

I’ve tried a few things, but I am overwhelmed by the information out there.

I’ve been to more than 3 practitioners trying to figure this out, and understanding or relief is still a mystery.

I have seen Melita for other offerings or completed other Zen From Within programs/events and am interested in delving deeper into my health concerns.

Other (please specify)

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* 7. Which of the following items are currently in your diet in ANY amount: (select all that apply)

Soda

Diet soda

Refined sugar

Alcohol

Fast food

Snack foods (chips, pretzels, etc.)

Dessert/candy (chocolate, cookies, candies, Twinkies, etc.)

Gluten (wheat, rye, barley)

Dairy (milk, cheese, yogurt)

Coffee

Please include any additional notes, here.

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* 8. What percentage of your meals are currently home cooked?

Less than 25%

25-50%

50-70%

70-100%

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* 9. We are committed to working with individuals who are dedicated to their health and ready to receive support on their individualized journey. We are uniquely poised to uncover and unlock the evolving diet and lifestyle modifications that will deliver the results you've been seeking.

In two or three sentences, tell me something about yourself and/or your health history that will help me to get to know you before we take any further steps to dig more deeply into the details of your concerns.

Once we receive your survey, we will be in touch to schedule your complimentary 15 minute Free Strategy Session (phone call)... we usually respond within 24 hours.

PLEASE check your spam box. This email will be coming from Melita@ZenFromWithin.com