Health & Wellness Evaluation Form
Full Name
First Name
Last Name
E-mail
example@example.com
Phone Number
Format: (000) 000-0000.
Where did you find me?
Instagram
Facebook
Referred by a friend
In person
Other
What is your Instagram/ Facebook name?
How long have you been following me on social media?
Have you ever used Herbalife or spoken to another distributor before?
Yes
No
Have you ever been a Herbalife Nutrition Member?
Yes
No
How old are you?
Height if known
Weight if known
What are the main reasons you are seeking wellness advice?
Weightloss
Detox
Help to maintain weight
More energy
Dietary advice
Sports enhancement
Immune support
Support in Pregnancy/ breastfeeding
Digestive support
Other
Do you eat breakfast?
Yes
Sometimes
Never
Do you often skip breakfast?
Yes
No
Do you eat 3 meals per day?
Yes
Sometimes
Never
What's a typical day of eating look like for you?
How do you rate your current level of health?
1
2
3
4
5
Poor Excellent
How do you rate your current level of energy?
1
2
3
4
5
Poor Excellent
Do you get tired throughout the day?
Yes
No
Sometimes
Do you excercise?
Never
1-2 times a week
3-4 times a week
5-6 times a week
Everyday
How serious are you about achieving your goal?
1
2
3
4
5
6
7
8
9
10
Serious Very Serious
Do you drink alcohol?
Yes
No
How often?
Do you have trouble getting to sleep?
Yes
No
How many hours sleep do you get a night?
Do you smoke?
Yes
No
Occasionally/ Socially
Are you currently pregnant or breastfeeding
N/A
Pregnant
Breastfeeding
Trying to conceive
What are you hoping to achieve from the program?
Are you looking to make an extra income?
Any extra information you wish to share?
Thank you for taking the time to fill in this Health & Wellness evaluation!
I'll be in touch with you soon! Jillian, Herbalife Distributor x
Submit
Should be Empty: