Wellness Evaluation
Habits - Nutrition - Mindset - Exercise - Community Support
Name
First Name
Last Name
Email
example@example.com
Whatsapp number
-
Area Code
Phone Number
Gender
Male
Female
How did you hear about us?
Please provide a name of the person who sent you the link
What do you have for breakfast?
Please write food and drink or N/A
What do you normally have for mid morning snack?
Please write food and drink or N/A
What do you usually have for lunch?
Please write food and drink or N/A
What do you normally have for afternoon snack?
Please write food and drink or N/A
What do you generally have for dinner?
Please write food and drink or N/A
Do you snack in the evenings, food /drink?
Please give an example what you snack on in the evenings
How many coffees/energy drinks drinks do you have per day?
How much water do you drink daily on average?
0-0.5L
0.5-1L
1-1.5L
1.5-2L
2L+
How many times did you exercise in the past 7 days?
0
1
2
3
4
5
6
7
How many hours of sleep do you get on average per night?
Please type the number of hours you sleep per night
How are your energy levels, on a scale from 0-10?
Please write a number, 0 worst, 10 best
What is your physical state at the moment, on a scale from 0-10?
Please write a number, 0 worst, 10 best
Do you know how much protein you consume in a day? Do you know how much your body needs daily?
Yes
No
Maybe - I would like to be sure
What are your main lifestyle CHALLENGES? (choose as many as you like)
Digestive issues (bloating, constipation, diarrhea, irregular etc)
Low Energy Levels
Low Immune System
Overweight
Underweight
On medication
Skin/hair, health issues
I need a better plan around my daily habits
Lack of support in my environment
Eating healthy is complicated
I don't have time to exercise
I forget to eat
I give up on lifestyle change
I'm harsh on myself if I make mistakes
Too much cravings
I don't like exercising
I procrastinate
Other
What are your goals
Improve Energy Levels / Mood
Weight Management
Weight / Muscle Gain
Healthy & Fit Lifestyle
Feel Better About Myself
Calm / Less Stressed
Improve Exercise / Sport Performance
Healthier Digestive System
Skin Care
Better Sleep
Other
Please add any other health /body/life goals you have:
Please share with me why it's important for you to reach your goal?
How ready are you to improve your energy, health & fitness levels, on s scale from 0-10?
0 not ready, 10 ready to start
Do you have a Coach that´s supporting you?
Yes / No / in what way
Why LEVEL 10 CLUB?
Personal Wellness Coach
Partnership with Herbalife nutrition - Simple & Effective Solutions
Positive Online Environment for Participants, Step by Step
Habits Improved at Home & On the Go!
Loyalty & Reward Plan, Pricing Privilegeds, Free Products, Income Possibilities.
Your next step, choose 1 -2 - 3 or 4:
Please Select
1. Trial: Improve nututritional and protein intake. One week trial R350
2. Start a wellness journey, 5 sessions in person R495Please
3. Start a wellness journey online, 10 Days, using Herbalife shake
4. I would like to discuss a personalised program with my coach.
Please choose one option
Your Next Step:
1. Trial: Improve nutritional & protein intake. Includes 9 smoothies and coaching. R350
2. Start a Wellness Journey, focus group: 5 sessions in person with refreshments. R495
3. Start a Wellness Journey, online 10 days & using a Herbalife shake (discounts apply)
4. I would like to discuss a personalised program with my coach
Have you used Herbalife Nutrition before?
Yes, currently a member
Yes, used to be a customer / member
No this will be my first time.
What is your budget for your Wellness Program
R800-R1100
R1000-R1500
R1500-R2000
R2000-R2500
R2500+
Are you interested in:
Joining the Loyalty program (Discount)
Part Time Income
Full time Income
No thanks, I’m not interested in benefits & rewards
Bonus Question: We are looking for Level 10 Assistant Coaches! People (at all ages) who have Passion for Health & Wellness, their own and would like to support others in getting healthier. We work from home or in clubs, 7-10h/week. Would you like to know more about it and the rewards that come with it?
Extra Bonus Question: Would you like to offer this evaluation to a friend(s)? Please pop their name/number below & forward them my link. - More names will increase your chances of winning my lucky draw :)
Please type name& numbers of your friends that you will forward the link to, thanks.
I´m looking forward to supporting you on your journey towards your goals!
Submit
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