Wellness Coaching Questionaire
Name
*
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Age:
Height (cms)
Weight (kg)
Have you heard of or used Herbalife Nutrition before?
*
If previously used, can you remember the name of your Wellness Coach?
What is your current activity level?
None - do not actively exercise / sit down job
Moderate - light walking
High - heavy labor intensive job / run 2+ times a week
Sporadic - no set schedule / I am active when time allows
How much weight (kgs) would you like to lose/gain, or what is your health goal?
*
What have you tried before? and Why did it not work for you?
*
Do you eat 3 meals a day?
Please Select
Yes
No
If no, which meal do you skip?
Do you snack throughout the day or night? What are your typical snacks?
How much water do you drink daily?
1 - 2 glasses
2-4 glasses
5+ glasses
what's water?
What else do you drink?
Please rate your readiness for change: (1 not ready & 10 absolutely ready)
*
1
2
3
4
5
6
7
8
9
10
What do you need the most help with?
Just starting!
Accountability
I've hit a plateau & I need help changing that
Other
Are you willing to financially commit to changing your life?
*
Yes
No
How do you prefer to be contacted?
Call
Text
Email
Other
I am so excited that you decided to reach out to me. I can't wait to help you with your health and wellness goals! I'll reach out to you in 24 hours
Submit
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