Wellness Evaluation Form
Please complete this wellness assessment to help us understand your health status and wellness goals.
Full Name
*
First Name
Last Name
Gender
Please Select
Female
Male
Date of Birth
*
-
Month
-
Day
Year
Date
Height
Weight
What is your main goal? (Loss weight, Gain Muscle, Energy)
Why is this goal important to you?
What are you looking for?
Guidance on what to eat
Consistency
Accountability
Community
What do you feel is stopping you from reaching your goal?
How would you describe you daily activities? (Besides the gym)
Sedentary (i.e. Desk job sit most of the day)
Light activity Spend a good part of the day on your feet (teacher, stylist...)
Moderate - Spend most of the daoing physical activity (waitress, mailman etc)
Very active - Spend most of the day doing hea y physical activity (construction, warehouse, etc.)
How often do you exercise per week?
3 days or less
4 days or more
Not at all
Not consistently
What do you currently eat throughout the day? (What did you eat yesterday?)
Will you be working out at home or gym facility?
Home
Gym
Just looking for nutrition plan no workouts.
Not sure
Have you tried Herbalife products before?
*
First time
Yes years ago
Currently on products
When would you like to start?
I'm ready Today!
In a couple of days
Next week
Not sure yet
How much are you currently able/willing to invest?
$135+
$180-$200 .... I'm ready
$250-$300 ... I'm All In!
Other
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Submit Evaluation
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