🌱 Wellness Profile Form
Please fill out this form to help me create a personalized wellness plan for you.
Name
*
First Name
Last Name
Date
*
 -
Month
 -
Day
Year
Date
Age
*
Height (in cm)
*
Weight (in kg)
*
Gender
*
Male
Female
Other
What is your main wellness goal?
*
Lose weight
Gain muscle
Improve energy
Healthy digestion
Better nutrition habits
Maintain weight
Other
What is your goal weight? (in kg)
*
When would you like to reach that goal?
*
 -
Month
 -
Day
Year
Date
What motivates you to make this change right now?
*
How many meals do you typically eat per day?
*
How often do you skip meals?
*
Never
1–2x/week
Almost daily
How much water do you drink each day? (in liters)
*
How many cups of coffee, tea, or soda do you drink daily?
*
What do you usually eat for Breakfast?
*
What do you usually eat for Lunch?
*
What do you usually eat for Dinner?
*
What do you usually eat for Snacks?
*
Any food sensitivities or dislikes?
*
How active are you?
*
Sedentary
Lightly active
Moderately active
Very active
What type of exercise do you enjoy?
*
How many hours of sleep do you typically get each night?
*
How would you rate your energy level most days?
*
Low
Medium
High
Occupation
*
Do you experience:
*
Cravings for sugar or carbs
Bloating/digestion issues
Afternoon fatigue
Trouble focusing
Irregular meals
Stress eating
Do you currently use any supplements or Herbalife products?
*
Yes
No
If yes, which ones?
*
Any health concerns or medical conditions?
*
How much guidance would you like?
*
Basic plan
Step-by-step meal guidance
Full accountability & check-ins
What’s your biggest challenge when it comes to healthy eating or staying consistent?
*
On a scale of 1–10, how committed are you to your goal right now?
*
1 (Not committed)
1
2
3
4
5
6
7
8
9
10 (Very committed)
10
1 is 1 (Not committed), 10 is 10 (Very committed)
Submit
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