coach Slim's Online Health Assessment
Name
*
First Name
Last Name
Email
example@example.com
Phone Number (WhatsApp friendly)
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
how did you find me?
*
facebook
tiktok
instagram
a friend
Corporate wellness talk
Other
select all that apply
i need to lose weight
i need to gain healthy weight
i need to tone up
i need energy and vitality
i need better skin
i need a healthy snacking option
Weight
In kg's
Height
In metres
Age
*
Gender
Male
Female
Other
occupation?
What is your energy level ?
1
2
3
4
5
6
7
8
9
10
What do you generally have for breakfast?
What do you generally have for lunch?
What do you generally have for dinner?
Do you have snacks during the day?
If yes, please list them
Do you exercise?
Yes
No
Do you have any medical concerns?
*
If yes, please list them
Are you currently using any medication?
*
If yes, please list them
WHY DO YOU NEED TO ACHIEVE YOUR GOAL?
*
If yes, please list them
whAT IS your budget
*
R900-R1000
R1000-R1500
R1600-R1900
R2000-R2500
R2600-R3000
R3100-R4000
ALL BUNDLES INCLUDE MEAL PLAN., WORKOUT PLAN AND hERBALIFE SUPPLEMENTS
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Are you a herbalife distributor?
*
Yes
No
HAVE YOU USED THE HERBALIFE PRODUCT BEFORE?
*
Yes
No
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