WELLNESS PROFILE
First & Last Name
Email
Phone Number
Address
Birthday
Current Weight & Height
What are your wellness goals? How many pounds would you like to lose or what is your current goal?
What have you tried before and why did it not work for you? What other wellness programs/products have you tried in the past to achieve your nutrition goals? What results have you experienced with these programs/products?
Do you eat 3 meals a day? If no, which meal(s) do you skip? What did you eat yesterday?
Do you snack? If yes, what do you snack on?
How many servings of fruits and veggies do you eat per day?
How many times during the week do you eat out? Where? Average cost per meal?
How much water do you drink during the day? What else do you drink? Tea, Juice, Soda, Alcohol, Coffee, Energy Drinks?
When are you most tired? Where is you energy level overall, on a scale of 1 to 10?
When are you most hungry?
Do you take any supplements?
How many hours of sleep do you average per night? How would you rate your quality of sleep?
How many times per week do you exercise for at least 20 minutes?
Would you be interested in receiving more information about products in the following categories? Please mark all that apply.
Core Nutrition/Weight Management
Digestive Health
Stress Management
Immune Health
Heart Health
Healthy Aging
Men's/Women's Health
Children's Health
Energy & Fitness
Outer Nutrition
Sports Nutrition
I would love a 3 day trial pack of products to support my weight loss/management and to boost my energy levels!
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