Health & Wellness Evaluation

1. Do you eat breakfast?*

YesSometimesNever

2. Do you eat 3 meals per day?*

YesSometimesNever

3. Do you ever participate in sport or exercise?*

DailyWeeklyRarelyNever

4. What is your goal?*

Lose Fat/Tone UpGain Healthy WeightMore Energy

5. How serious are you about achieving your goal?*

	1	2	3	4	5	6	7	8	9	10

1 is Curious, 10 is Very serious

please leave your contact details below and we will get back to you within the next 24 hours. Our product website is www.eatlikeus.goherbalife.com if you would like to have a look in the mean time.

Full Name*

First NameLast Name

Phone Number*

Area CodePhone Number

E-mail*

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Thank you for completing our survey.