Introduction Survey — Backes Wellness

Full Name

First Name

Last Name

What can we help you with?

Give us an overview of where you are at today with your wellness. Please do NOT submit any medical information.

Do you struggle with? Check all that Apply:

Poor Eating Habits?

Too Many Processed Foods?

Cravings for sweets and desserts?

Staying on any eating plan?

A Support System to help you stay strong?

Lack of motivation to stay fit?

How many times have you made attempts to improve your health before, and with which programs?

Help me get to know you!