Wellness Evaluation Form

  • Personal Wellness Evaluation

    Nutritional Assessment

  •  

    Hi Lovely 👋, I'm Coach Melinda.

    My mission is to help you reach your health & wellness goals and transform how you look and feel everyday with my simple 3 Steps Plan, and to support you living your best life!

     

     

    Firstly, WELL DONE 👏 for taking the steps to transforming your health.  Let's begin. 

    Based on the information you provide in this form, I will provide a detailed Wellness Evaluation / Meal Plan to help you achieve your health & wellness goals.  

    The Wellness Evaluation will act as a roadmap taking you from where you are today to where you want to be.

    Let's start by filling in the form below.

     

  • Date of Birth*
     - -
  • Gender*
  • Format: (000) 000-0000.
  • When is a suitable time to phone you?*
  • How are your energy levels during the day?*
  • Do you often feel bloated or have difficulty going to the toilet?*
  • What is your breakfast routine like? Tick all that apply.*
  • Do you eat a variety of colourful fruits and vegetables?*
  • Do you drink at least 8 glasses of water a day?*

  • How often do you do the following:

  • Sweets*
  • Baked goods (biscuits / pies / cakes)*
  • Takeaways*
  • Fizzy drinks*
  • Alcohol*
  • How often do you EAT OUT a week (this includes takeaways)*
  • How much do you spend on meals each day? This includes snacks, drinks and meals*
  • What are your health goals currently? (tick all that apply)*
  • How serious are you about reaching your health goals?*
  • Do you suffer from any of the following health issues? (tick all that apply)*

  • DISCLAIMER:

     

    It is advised that you consult your doctor before participating in any nutritional program.  All results are specific to the individual and are based on following the Herbalife Nutrition program which is combined with healthy lifestyle.

     

     

    Refer 3 friends or family who you think would benefit from a FREE WELLNESS EVALUATION

     

    Please list their names and mobile numbers below:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • That's the end of the Wellness Evaluation

    Click below to submit

  • Should be Empty: