10 Day Express weight loss Challenge - Wellness Profile!
Who referred you to this Marathon?
*
Name
Full Name
*
First Name
Surname
Gender
*
Male
Female
Email
*
example@example.com
Which Town and Province do you live in?
*
What is your biggest challenge in losing weight? (e.g eating healthy snacks)
*
Whatsapp Phone Number
*
-
(082 ect)
Phone Number
Age
*
years
Height
*
cm
Weight
*
KG
Have you ever used Herbalife Nutrition products before?
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Yes
No
If YES, how long ago?
Whats the activity level at your job?
*
None (seated all day)
Moderate (light activity such as walking)
High (heavy labor, very active)
How many Kgs would you like to lose?
*
Do you eat 3 meals a day?
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Yes
No
If no, which meals do you skip?
Breakfast
Lunch
Dinner
Do you generally snack?
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Yes
No
How many days a week do you eat out?
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1-3
3-5
over 5
never
How much water do you drink daily?
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1 glass
2-3 glasses
1 to 2 Litres
3 Litres
What's water?
Please rate your commitment to achievement of your goal?
*
1
2
3
4
5
6
7
8
9
10
Why?
*
Submit
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