Health & Lifestyle Questionnaire

Do you feel that you receive balanced nutrition from the foods you eat?

YesNo

How would you describe your energy levels?

AmazingOkUp & DownTerrible

Would you like to:

Gain weightMaintain WeightLose your bellyBe nice & lean or get ripped

How much would you like to lose/gain?

Do you exercise?

Not at allOccasionallyRegularly

Do you have any health concerns?

I work with Herbalife International and help people with their nutrition. I personally have had great results myself: -

I Used to:

- Smoke a pack of cigarettes a day

- Eat takeaway convenience foods 3-4 times per week

- Never exercised

- No energy

- start weight 103kgs

Now:

- I no longer smoke

- No more fast foods

- Way too much energy throughout the day

- Weight train x5 days a week and cardio twice a week

- Happy to annouce I am 40kgs lighter

A) For R150 can I offer you ?

6 Day Healthy BreakfastNo

B) Can I call you with more information about the Challenge?

YesNo

C) If I can show you how to make an extra R1000-R7000pm without effecting your job working from home would you be interested?

YesNo

Name

First NameLast Name

E-mail

Phone Number

Area CodePhone Number