Health & Wellness Survey

Health & Wellness Survey
Complete our survey below

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Name*

First NameLast Name
Cellphone / WhatsApp Contact Number*
Please enter a valid phone number.
Where are you from? Eg. Claremont, Cape Town*
Who referred you to us?

First NameLast Name
How would you rate your current state of health?*

GoodAverageNeeds urgent attentionExtremely Healthy
What are your goals?*

Lose WeightTone UpGain Lean MuscleMore EnergyDrop Body FatLive a Healthier LifestyleJoin a positive communityFree Nutrition Education & TipsStart an exercise programMake an extra income
Do you feel you are getting balanced nutrition daily from the foods you eat?*

YesNoSometimes
Do you have Breakfast?*

YesNoSometimes
What does your average breakfast look like? *
Your answer
Do you eat 3 meals per day?*

YesNoSometimes
Do you snack throughout the day?*

YesNoSometimes
How would you describe your energy levels throughout the day?*

Little to none, I really have to push through both mornings and afternoonsGood energy in the morning, but I have an energy slump in the afternoonsStruggle with my mornings, but I am full of energy as they day goes onI have great energy throughout the day and don't notice any dips
Would you like to improve your energy levels?*

YesNo
How often do you exercise?*

1 - 3 Times per week4 - 5 Times per weekEveryday including the weekendsI don't exercise
How much water do you drink per day?*

1 - 2 Litres2 - 3 LitresMore than 3 Litres1 Litre on a good day
On a scale of 1 - 10 how serious are you about your goals?*

12345678910
What are you prepared to spend monthly on your health & wellness goals?*

R200 - R500R500 - R1000R1000 - R2000R2000 - R3000R3000 +R0 my health is not a priority to me
Have you tried Herbalife Nutrition products before?*

Yes, I'm currently on a program with a CoachNo, I would love to hear more from you :)I have tried the products before, I'm ready to try the lifestyle againI have tried the products before & didn't have a great experience
Would you be interested in earning an extra R3000 to R5000 per month or look at a larger income opportunity?*

Refer 3 Friends that you think they would like to take part in our survey.

	Name	Surname	Whatsapp Number
Referral 1
Referral 2
Referral 3

Should be Empty:

Health & Wellness Survey

Complete our survey below