Wellness Evaluation
Answer each question completely and to the best of your ability.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email(optional)
example@example.com
Age range
Over 65yrs
50yrs - 65yrs
40yrs - 50yrs
30yrs - 40yrs
18yrs - 30yrs
under 18yrs old
How would you rate your overall physical health?
*
Excellent
Good
Fair
Poor
How many meals do you eat in a day.
3 or more
At least 3
1 - 3
1 (with a lot of snacking)
Are you able/capable to engage in physical activity/workkut, OR UN-able to due to an injury or disability
Yes - I can workout
No - I can NOT workout
Not able(due to injury)
Limited(due to injury or disability)
Not willing to at this time
How often do you engage in physical activity each week?
*
Daily
3-5 times
1-2 times
Rarely
N/A
Do you work a full time/part time job? How many days do you work in a week?
Every day(7 days a week)
5 days a week(2 days off)
4 days or less
Varies
How would you describe your current stress level?
*
Very high
High
Moderate
Low
Which of the following best describes your sleep quality?
*
Very good
Good
Fair
Poor
How are you with accountability?(Sticking to your meal plan/fitness plan)
Very good/rarely need help.
Fair/need help sometime
Work in progress/ need to improve
Below average/ HELP ME!!! 😩
Have you ever used Herbalife products/supplements OR worked with an Herbalife Health Coach before?
Yes
No
Don’t Remember
If “Yes” how long ago was it?
Still currently
Less than a year
Over a year
More than 2 years
What interest you the most and what do you hope to gain during your health/wellness journey? (check all that apply)
Physical results(weight loss/gain)
Community
Improve overall health quality
Improve mental health quality
Personal development
Business/Income opportunity
Is there anything you would like to share about yourself that would be helpful in assisting us with your journey or achieving your goals?
Submit Evaluation
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