HEALTH AND WELLNESS EVALUATION

HEALTH AND WELLNESS EVALUATION

WITH HERBALIFE
First Name Last Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Where did you find us?

Other
What is your Instagram?
What is your Facebook?
How long have you followed me on social media?
Have you ever used Herbalife or spoken to another Distrabutor?
Have you ever been a Herbalife member?
Do you eat breakfast?
Do you often skip breakfast?
Do you eat three meals a day?
Whats a typical day of eating like for you?
What is your goal?

Other
How serious are you about achieving your goal?

1

2

3

4

5

1 is 50%, 5 is 100%
How old are you?
Roughly how tall are you?
weight if known?
what reason are you seeking wellness advice?

Other
Do you exercise?
How do you rate your current health?

1

2

3

4

5

1 is Poor, 5 is Excellent
How do you rate your energy?

1

2

3

4

5

1 is Bad, 5 is Amazing
Do you get tired throughout the day?
How many Litres of water do you drink in a day?
Do you drink alchol?
How often do you drink alcohol?
Do you struggle to fall asleep?
How many hours of sleep do you get a night?
Do you have any known allergies?
Do you smoke?
What are you hoping to achieve from the program? Any additional info you’d like to share?
Thankyou for taking time to fill out the information provided in this health and wellness evaluation!

I will be in touch with you as soon as i can and I look forward to talking further with you.

Shanique
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