Wellness Drop- In Pre Registration

Wellness Drop In - Pre Registration

Fill out completely and to the best of your ability.
Have you worked with a Herbalife Health Coach before?
Full name *

First Name Last Name
Birth Date *

Month Day Year
E-mail *
FB/ IG Handle *
Phone Number *

Area Code Phone Number
Preferred Method of Contact *

Phone Text Email Messenger
How did you hear about Virtual Health? *
Declare where you are and where you wish to be.

When we get clear - we can build a support structure.
Describe where you are in your health journey now. (Health, Weight loss, Sleep, Stress, Energy) *
Describe where you want to be. (Health, Weight loss, Sleep, Stress, Energy) *
Describe where you want to be. (Health, Weight loss, Sleep, Stress, Energy) *
Describe WHY you are interested in getting healthy (what is your motivation?) *
When was the last time you remember feeling your best or your ideal weight/ size? *
What do you feel has challenged you the most in your health journey? *
Medical
Are you pregnant?

yes no
Are you nursing?

yes no
How old is your baby?
Do you have the following?
Are there any allergies I should be aware of?
Are you taking any medications?
Are you taking any medications or have any conditions that would influence the program we choose for you?
Sleep
How many hours do your typically get?
Describe your night time routine.
How is your quality of sleep?
Do you wake up feeing rested?
Do you wake up at the same time every day?
Hydration
How much water do you drink a day?
How much soda do you drink a day?
How much coffee a day?
How much tea a day?
Do you have any meal replacement shakes?
Movement
How would you rate your movement routine now? Scale 1 (no movement -10 (work out a lot!)
What is your energy level? Scale 1 -10 (1 zero energy - 10 full of energy!)
Are there any movements you can not do due to injury?
What is something you'd like to learn during this healthy lifestyle experience?
Stress
How would you rate your stress level? Scale 1 -10 (not stressed - super stressed!)
How much to do you enjoy what you do?
What is your passion?
What do you do for work?
Are there any other stressors in your life?
Meal Planning
When do you have your first meal?
How many healthy meals do you have a day?
How many times do you eat out a day?
Where do you eat out?
What does snacking look like during the day?
Do you use any meal services?
What does your last meal and snack of the day look like?
Do you meal prep?
Body Health
Do you have a positive or a negative self image?
Do you give up on your self easily?
Have you done any personal health deep work with a health coach before?
What is your weight/ BMI now?
What goal weight / BMI goal do you have?
What is most challenging about losing weight/ gaining weight or maintaining your weight?
Environment Health
How healthy would your rate your surroundings?
Do you have healthy active friends, family members in your court?
Is there any one who you'd like to join on your health journey?
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Wellness Drop In - Pre Registration

Declare where you are and where you wish to be.

Medical

Sleep

Hydration

Movement

Stress

Meal Planning

Body Health

Environment Health