Wellness Profile
Questionnaire
Personal Details:
Full Name:
Date of Birth:
Mobile:
Age:
Address:
Email:
Current Circumstances:
Occupation:
Occupation Activity Levels:
Smoker:
Yes / No
Sedentary / Moderate / Active / Intense
If yes then how many per day?:
Cost per week?:
Medical conditions, injuries, medication, allergies or intolerances?:
Other health struggles or issues? (tiredness, headaches, digestion, constipation):
Weekly Exercise:
Amount?:
Type?:
None / 1-2 / 3-5 / Every day
Light Cardio / Class Cardio / Weights / Heavy Weights
Sports / Hobbies?:
Wellness Profile
Questionnaire
Week Day Food & Drink Routine
Breakfast?:
Food:
None / Cereal / Toast / Porridge / Other
Drink:
None / Coffee / Tea / Fruit Juice / Water / Other
Mid Morning?:
Food: Cost?:
Drink:Cost?:
Lunch?:
Food: Cost?:
Drink:Cost?:
Mid Afternoon?:
Food: Cost?:
Drink:Cost?:
Dinner / Tea?:
Food: Cost?:
Drink:Cost?:
Before Bed?:
Food: Cost?:
Drink:Cost?:
Total Food & Drink Cost?:
Weekly Alcohol Units?:
Weekly?:
Cost?:
Monthly?:
Monthly Cost?:
Monthly Eating Out / Take-away: Number of times?
Total monthly spend on food and drink, not including weekends:
Cost?:
Wellness Profile
Questionnaire
Your General Goals (circle all that apply):
Weight Loss
Gain Weight
Clearer Skin
Fat Loss
Build Muscle
Stronger Hair
Toning
Sports Recovery
Stronger Nails
Feel Healthier
Endurance
Sleep Better
Extra Energy
Health Related
Feel Younger
Specific Goals:
By I would like to
Because
Signed:
Things that could stop you achieving the above?:
Thank you for taking the time to complete this questionnaire. My commitment to
you is that I will guide and support you every step of the way in making the small
but necessary changes to your daily routine that are required to help you achieve
all your health and wellness goals.
Your Herbalife Wellness Coach,
Wellness Profile
Questionnaire
Tanita Body Composition
Height:Age:
%
Time
Weight
Body
Fat %
+
-
BMR
Metabolic
Age
Bone
Mass
Visceral
Fat
L/Arm
R/Leg
L/Leg
TOTAL
18
6
21
5
4
3
2
Neck
20
Time
19
Date
Water % Physique
Rating
+
-
7
Body Measurements
Muscle
Mass
1-9
Chest
1
Date
%
Waist
Hips
R/Arm
Wellness Profile
Questionnaire
Personalising Your New Routine Breakfast
Mid Morning
Lunch
Mid Afternoon
Protein Target:
Dinner
Before Bed
Total Protein
Herbalife
Products
Protein:
Protein:
Protein:
Protein:
Protein:
Protein:
Protein:
Protein:
Protein:
Protein:
Protein:
Protein:
Protein:
Protein:
Food
Herbalife Protein Options
25g - Formula 1 (with PDM)
18g - Formula 1 (with Milk)
15g - PDM
10g - Protein Bar
10g - Soya Beans
10g – Soup
5g – Personalised Protein Powder (1 scoop)
Food Protein Options
30g – Chicken Breast (100g boneless and skinless)
24g – Turkey Breast (3oz)
23g - Beef Steak (3oz)
23g – Salmon / Tuna (3oz)
23g – Greek Yoghurt (8oz)
20g – Shrimp (3oz)
14g – Cottage Cheese (1/2 cup)
13g – Dried Lentils (1/4 cup)
20g – Tofu (1/2 cup)
8g – Edamame (1/2 cup)
8g - Quinoa (1 cup)
6g – Egg (large)
6g – Mixed Nuts (2oz)