Wellness Evaluation
Thank you for your interest in my fitness & nutrition online coaching! To better understand you and some of your goals, please fill out this evaluation completely and I will follow up with you as soon as possible!
Name
*
First Name
Last Name
Gender
*
Male
Female
Best Phone Number?
*
Please enter a valid phone number
Instagram Username
*
example@example.com
Age
*
years
What are your goals?
*
Lose weight
Tone up / lose belly fat
Gain lean muscle
Have more energy
Skin glow / hair growth / nail growth
Help with acne
Other
How soon are you looking to get started?
*
As soon as possible
Not sure - just looking for more information
How would you like to be contacted?
*
Text message
Email
Instagram
NUTRITION
Do you eat 3 meals a day?
*
Do you snack in between your meals?
*
What is your daily water intake?
*
Ex. 15 oz
Hours of sleep per night?
Ex. 4-6hrs
Have you ever tried Herbalife?
*
YES
NO
Never heard of it
If yes, how long ago?
*
Less than a year ago
Over a year ago
I am currently using Herbalife Nutrition
HEALTH
Exercise
Do you exercise?
*
YES
NO
If yes, how often per week?
*
1-2 days
2-3 days
Everyday
What is the activity level at your job?
none(seated only)
Moderate (light activity such as walking)
High (heavy labor, very active)
Does this vary much on the weekend?
Yes
No
How would you rate your sleep quality?
Very poor
Poor
Average
Good
Very Good
Reflection
What would this mean to you, once I helped you reach your goal(s) ?
*
Please rate your readiness for change
1
2
3
4
5
6
7
8
9
10
I am excited to help you start your journey to a healthier and happier you as your coach!
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