Wellness Evaluation

Ready to get F.I.T. ?
Here is how it works!

1. Fill out this free wellness evaluation form
2. We’ll set up a phone call or in-person meeting to create a personalized plan customized to your goals and needs.
3. Get Focused, Stay Inspired, and Transform Your Life!
Full Name*

First NameLast Name
Age*
years
Height*
ft
Weight*
lb
Target Weight*
lb
Phone*
Email*
How would you like me to contact you?*

CallEmailText
At what times during the day would you prefer a follow-up?*

MorningMid-DayAfternoonEvening
Have you ever tried Herbalife before?*

No, NeverYes, I'm currently working with a CoachYes, more than 6 months agoYes, more than 1+ years ago
What do you do for a living?*
What is your weekly schedule like?Do you follow a regular working schedule, do you work days, afternoon or nights, work from home, etc?*
What is your Activity Level per Week?*

InactiveActive (3)Moderate (1-2)Very Active (4+)
What are your Priorities? (CHECK ALL THAT APPLY)*

Lose WeightLean and ToneBuild MuscleOverall HealthEnergyPregnancy/Postpartum HealthLose Belly FatDigestive HealthWomen's HealthMen's Health
What is most difficult for you to reach your health/fitness goals? (CHECK ALL THAT APPLY)*

ConsistencyMeal Planning/PreppingDrinking Calories (iced coffee, alcohol, milkshakes, etc)Eating Out/Fast FoodUnmotivated/TiredNot knowing what to eat/not to eatHealth IssuesMenopauseOther (explain in additional info box)
If you have any diagnosed health problems, list the condition(s) or symptoms.*
If you have any injuries, please list them.*
Are you experiencing any stresses or motivational problems?*

YesNo
Your current diet could be best characterized as:*

low-fatlow-carbhigh-proteinVegetarian/VeganNo special diet
What do you hope to achieve with my coaching and nutrition plan and WHY? (Understanding your "why" keeps you focused and helps me, as your coach, guide and motivate you in a way that truly aligns with your goals.)*

Timeline for achieving your goal.*

	8 WKS	16 WKS	24 WKS	32 WKS	40 WKS	1 YEAR
Select one:

How soon are you ready to Start?*

TodayThis WeekNext WeekNext MonthI just want info
Any additional detail here:
Please verify that you are human*
Should be Empty: