Health & Wellness Survey
Complete our survey below
Follow me on instagram @yaasirhlf
Name
*
First Name
Last Name
Cellphone / WhatsApp Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Where are you from? Eg. Claremont, Cape Town
*
Who referred you to us?
First Name
Last Name
How would you rate your current state of health?
*
Good
Average
Needs urgent attention
Extremely Healthy
What are your goals?
*
Lose Weight
Tone Up
Gain Lean Muscle
More Energy
Drop Body Fat
Live a Healthier Lifestyle
Join a positive community
Free Nutrition Education & Tips
Start an exercise program
Make an extra income
Do you feel you are getting balanced nutrition daily from the foods you eat?
*
Yes
No
Sometimes
Do you have Breakfast?
*
Yes
No
Sometimes
What does your average breakfast look like?
*
Your answer
Do you eat 3 meals per day?
*
Yes
No
Sometimes
Do you snack throughout the day?
*
Yes
No
Sometimes
How would you describe your energy levels throughout the day?
*
Little to none, I really have to push through both mornings and afternoons
Good energy in the morning, but I have an energy slump in the afternoons
Struggle with my mornings, but I am full of energy as they day goes on
I have great energy throughout the day and don't notice any dips
Would you like to improve your energy levels?
*
Yes
No
How often do you exercise?
*
1 - 3 Times per week
4 - 5 Times per week
Everyday including the weekends
I don't exercise
How much water do you drink per day?
*
1 - 2 Litres
2 - 3 Litres
More than 3 Litres
1 Litre on a good day
On a scale of 1 - 10 how serious are you about your goals?
*
1
2
3
4
5
6
7
8
9
10
What are you prepared to spend monthly on your health & wellness goals?
*
R200 - R500
R500 - R1000
R1000 - R2000
R2000 - R3000
R3000 +
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 Coach
No, I would love to hear more from you :)
I have tried the products before, I'm ready to try the lifestyle again
I 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?
*
Please Select
Yes
No
I want to impact people
Refer 3 Friends that you think they would like to take part in our survey.
Rows
Name
Surname
Whatsapp Number
Referral 1
Referral 2
Referral 3
Submit
Should be Empty: