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Wellness Evaluation Form
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Shipping Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
My Goal is To (Check all that apply)
Lose weight
Tone up/ Lose belly fat
Gain lean muscle
Live a healthier life style
Have more energy
Skin glow/ hair growth/ nail growth
Help with Acne
What is your current weight?
Height
What is your goal weight?
What is your goal size?
Type a question
Clothing/ pants
How long will you give yourself to reach your goal?
How soon are you looking to get started?
As soon as possible
Not sure yet/ Just want more info
Other
Have you ever used Herbalife before?
Yes
No
If yes, how long ago?
Less than a year ago
Over a year ago
I am currently using Herbalife Nutrition
What other weight management goals do you have?
What do you typically drink throughout the day?
What do you typically eat throughout the day?
How much money do you spend on food/ snacks daily?
Not groceries
What is the hardest part about losing/ gaining weight for you?
Type a question
On a scale of 1 - 10, How great is your energy?
What time of day is your energy the lowest?
Type a question
How often do you exercise?
Type a question
Please list any medications or health conditions
Let's schedule a time to discuss your options based on your answers
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Month
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Day
Year
Date
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Hour
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10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Message for your future coach?
Optional
Submit
Should be Empty: