Health & Wellness Survey

Health & Wellness Survey
Name*

First NameLast Name
Phone Number / WhatsApp Contact *
Please enter a valid phone number.
Where you from? Idas, Cloetesville etc *
How would you rate your current state of Health?*

GoodAverageNeeds Urgent AttentionExtremely Healthy
What are your Goals?*

Lose WeightTone UpGain Lean Muscle MassMore EnergyDrop Body FatLive a Healthy 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?*
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 in the morning, but I am full of energy as the day goes on.I have great energy throughout the day, and dont 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 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? *

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
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 my coachNo, I'd 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, I never had a great experience

Refer 3 friends that you think would like to take part in our survey

	Name	Surname	WhatsApp Number
Referral 1
Referral 2
Referral 3

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