Health and Wellness Evaluation

Health and Wellness Evaluation
Full Name

First NameLast Name
What is your age?
What is your gender?
What is your height? (if known)
What is your weight? (if known)
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Country
Where did you find me?

Other
Instagram Name
Facebook Name
Are you currently following me on social media?
Have you ever used Herbalife or spoken to another Herbalife before?
If yes, please elaborate:
Do you eat Breakfast?
Do you often skip Breakfast?
Do you eat 3 meals per day?
What's a typical day of eating look like for you?
Do you often feel tired or get exhausted throughout the day?
How often do you exercise?
What are the main reasons you are seeking wellness advice?

Other
How do you rate your current health?

1

2

3

4

5

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

1

2

3

4

5

1 is Poor, 5 is Excellent
How many litres of water do you drink a day?
Do you drink alcohol?
How often?
Do you have trouble sleeping?
How many hours per night?
Do you smoke?
What are you hoping to achieve from the program? Any additional info you'd like to share?
Thank you for taking the time to fill in this form.

I will get back to you as soon as possible!

Sj 🌻 xx
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