Wellness Evaluation

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Name

Goals? *

Weight Loss

Weight Gain

Weight Maintenance

Do you take any workout supplements currently? *

Yes

What kind of workouts do you currently do, if any?

What time do you eat your 1st meal of the day?

How many meals do you eat a day? *

1 meal

2 meals

3 meals +

What are your go to snack options?

What are your protein preferences? (mark all that apply) *

Beef

Pork

Chicken/Turkey

Fish

Vegan

Vegetarian

Other

How many times a week do you have digestive issues? *

0 - 2

3 - 5

6 - 7

Do you take anything for digestive issues on a regular basis?

Age

Weekly Activity Level? *

Light

Moderate

Active

What do you like about what you take? What do you dislike?

What time do you get up in the morning?

How well do you sleep? *

4 to 5 hours

6 to 7 hous

8 + hours

What time do you get up in the morning?

How much water do you drink in a day? *

I hate water!

2 - 3 bottles

4 - 6 bottles

7+ bottles

Do you add anything to your water?

What other liquids do you consume daily?

What programs have you tried before?

What did you like about that program?

What did you dislike about that program?

What questions would you like to have answered in a consultation?

Your email address

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CONTACT ME

Shane Weckerly

Herbalife Independent Distributor
775-771-5038
shane@desertskynutrition.fit

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