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FREE WELLNESS EVALUATION

What we eat and our lifestyle choices influence our health, energy levels and general well being. In order to make positive changes you need to have a basic understanding of the principles of nutrition. Let us help you identify your areas of concern and adapt this knowledge, along with appropriate changes, to your daily routine.

Please complete the questionnaire below in order for us to make recommendations to help you achieve your goals, be they weight loss, weight maintenance or general health matters. We respect your privacy and as such will treat all information as strictly confidential. Information will be used solely for the purpose of Herbalife-Direct and will not be disclosed to any third party.

PERSONAL DETAILS (* Fields must be completed)

Name:*

Surname:*

Email:*

Height:*

PLEASE INDICATE WHETHER IN METRES (eg. 162cm) or
IN FEET (eg. 5'2")

Weight:*

PLEASE INDICATE WHETHER KILOGRAMS OR POUNDS

Age:*

Country:*

Gender:*

Male   Female
   

PLEASE ANSWER THE FOLLOWING QUESTIONS AS ACCURATELY AS POSSIBLE

1. Do you eat more meals with poultry, lean meat, fish and soy proteins rather than steaks, roasts and other red eats?..............................................

   
Yes No

2. Do you eat a variety of colorful fruits and vegetables and do you eat at least five servings a day of these?..............................................................

   
Yes No

3. Do you consume primarily whole grains (100% whole wheat bread and pasta, brown rice) rather than regular pasta, white rice and white bread?

   
Yes No

4. Do you eat oily fish (such as salmon, mackerel, sardines, trout) at least three times a week?..........................................................................................

   
Yes No

5. Do you avoid the intake of fried foods, dressings, sauces, gravies, gravies, butter and margarine?.......................................................................

   
Yes No

6. Is your digestive system free of indigestion or irregularity?......................

Yes No

7. Do you get a minimum of 30 minutes of exercise five days a week?........

Yes No

8. Do you maintain a stable and appropriate weight?...................................

Yes No

9. Do you usually have time to prepare balanced meals, rather than take aways or eating on the run?.............................................................................

   
Yes No

10. Do you stay away from fizzy drinks and typical snack foods throughout the day and after dinner?............................................................

   
Yes No

11. Are you free of water retention and bloating?.........................................

Yes No

12. Do you have the energy and focus you need to meet your daily challenges?........................................................................................................

   
Yes No

13. Do you drink at least 8 glasses of water per day?....................................

Yes No

14. Do you ever suffer from aching and tired joints or muscles?..................

Yes No

15. Do you tend to catch colds frequently with a slow recovery rate?........

Yes No

16. Are your blood pressure, triglycerides and cholesterol in the normal range?................................................................................................................

   
Yes No
     

What are your nutritional goals:

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