WELLNESS EVALUATION
Hey hey! I am so excited to help you in becoming a BETTER YOU! Fill out this form to tell me more about yourself, so I can better understand, and support you in your goals. When you’re done, I will reach out to you as soon as possible to get started! ONLY fill this out if you’re serious in getting started! ☺️
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Instagram name:
*
How would you like to be contacted?
*
Text message (US and Canada only)
Email
Gender
*
Female
Male
Where are you located? City/State.
*
Country:
*
Age/Height/Current Weight?
*
What are your goals? Pick 1.
*
Lose weight.
Gain healthy weight/lean muscle.
Increase athletic performance.
Tone up.
Have more energy.
I would like to eat better and have a healthier lifestyle.
How much do you spend on food weekly? Ex. Dine in, drive thru, or take out.
*
$0-5
$5-$10
$10-$20
$20+
What is your budget?
$100
$100-$150
$150-$200
$200-$250
Whatever it takes!
How much help water (bottles of water in oz.) do you drink daily?
*
No water.
1-2 bottles.
3-4 bottles.
5+ bottles.
How many times per week do you exercise?
*
1-2
3-4
5+
None
Do you drink coffee?
*
Yes
No
Do you have any food allergies? If yes, please explain, if no put none.
*
Are you taking any medications?
*
Yes
No
Have you ever used Herbalife Nutrition before?
*
Yes
No
If yes, how long ago? If no, select does not apply to me.
*
Less than a year ago.
Over a year ago.
I am currently using Herbalife Nutrition.
Does not apply to me.
Are you also interested in learning more about the Herbalife Business Opportunity?
*
Absolutely!
I am open to learning more.
No, I am only interested in using the products.
Not now. Maybe in the future.
How serious are you about achieving your goals?
*
I’m ready to start TODAY!
THIS WEEK!
THIS MONTH!
If you’re a member or a distributor, please reach out to your sponsor. Thank you.
Submit
Should be Empty: