WELLNESS PROFILE QUESTIONNAIRE
*Please answer each question down below*
Client Information :
Full Name
*
First Name
Last Name
Age
*
Cell Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Do you prefer contact by phone, email or text
*
Phone Call
Email
Text
What is the best time of day to reach you?
Please Select
Morning 9-11
Afternoon 12-3
Evening 6-8
Wellness Goals :
What are your main health goals
*
Fat Loss
Muscle Gain
Better Digestion
Better Energy
Better Sleep
Less Stress
Improved Nutrition
Other
Where do you tend to gain weight or store fat the most? (Belly, hips, legs, arms, etc.)
*
What areas do you need the most support with?
*
With nutrition
With the workouts
With my mindset
All of the above
Other
How much time are you willing to give yourself to achieve your goals
*
30 days
3 months
6 months
As long as it takes
Current Diet :
What did you have for breakfast, lunch, dinner and snack yesterday
*
How many caffeinated or sugary beverages (coffee, tea, energy drinks) do you consume per day?
*
Have you ever followed a structured nutrition or workout program?
*
Yes
No
Have you ever used Herbalife before? If yes, when was the last time?
*
What other weight loss programs have you tried in the past?
*
Why do you think they didn't work for you?
What’s been holding you back from reaching your goals until now?
*
Do you have any known allergies, sensitivities or dietary restrictions?
*
How often do you currently exercise?
*
Where do you usually exercise?
*
Gym
Home
Outside
I don’t exercise
What’s your current monthly wellness budget?
*
$100-$150
$150-$200
$200-$250
$250+
Is there anything else you’d like me to know?
*
Submit
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