Free Wellness Evaluation

Based on the information given below, I will provide a detailed Wellness Evaluation / Meal Plan to help you achieve your current health/fitness goals. This wellness evaluation will act as a roadmap taking you from where you are today to where you want to go. As health coaches we know that in order to reach your goals, it takes 20% fitness, 80% nutrition and 100% mindset. If you're ready, let's begin!

Fields marked with a (*) must be filled in please

Name*

First NameLast Name

Date of Birth*

MonthDayYear

Contact Number*

When is a good time to phone you

MorningAfternoonEvening

Whatsapp Number if different from contact number.

E-mail*

Real results for real people. Whether your goal is to

* Lose weight

* Gain weight

* Shape up

* Increase energy

Then this is for you. See some of our many results from all over the world below

Gender*

MaleFemale

How are your energy levels during the day?*

What time do you usually go to bed?*

What time do you wake up?*

Are you often bloated or have difficulty going to the toilet?*

YesNo

Do you often feel tired during the day?*

YesNo

What is your breakfast routine like? (tick all that apply)*

Do you eat a variety of colourful fruits and veg?*

YesNo

Do you drink at least eight glasses of water per day*

YesNo

Sweets*

NeverSometimesOftenDaily

Baked goods (biscuits/pies/cakes)*

NeverSometimesOftenDaily

Take aways*

NeverSometimesOftenDaily

Fizzy drinks*

NeverSometimesOftenDaily

Alcohol*

NeverSometimesOftenDaily

How often do you EAT OUT a week (this includes take aways)*

Hardly ever1-2 times3-4 times

How much do you spend on meals every day? This includes snacks, drinks and meals*

R40-R60 per dayR70-R100 per dayR110-R150 per dayR160-R200

What are your health goals currently? (tick all that apply)*

What is your why? Is there an event you are working towards? Or do you want to clean up your lifestyle? Be specific!*

How serious are you about your health goals?*

Not verySort ofSeriousVery serious

List any vitamins/supplements you currently take*

What kind of physical exercise do you do and how often (if any)*

Do you suffer from any of the following health issues? (tick all that apply)*

Medical Conditions*

Do you have any medical conditions or injuries that Coach needs to be made aware of?

If yes, please specify:

Disclaimer:

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

Please list 3 friends or family who you think would benefit from doing this FREE WELLNESS EVALUATION

Please list Name and whatsapp number.

Eg: Pamela McLean, 076 485 1251

Friend 1

Whatsapp Number

Friend 2

Whatsapp Number

Friend 3

Whatsapp Number

NOW THAT THE HARD WORK IS DONE

CLICK THE LINK BELOW TO SUBMIT

HI, I'm your Coach PAM

Coach Pam