Portage Nutrition Personal Health & Wellness Profile
Wayde Drain Call/Text 204-872-4372 Herbalife Team Member
Full Name
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First Name
Last Name
E-mail
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Phone Number
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Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Height (feet/inches)
Weight (pounds)
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How much weight do you want to lose/gain? And why?
Why do you want to lose/gain this much?
What other programmes/products have you tried in the past?
Why do you feel that these other programme(s) did not work?
What is your biggest struggle when trying to lose/gain weight?
How many times a day do you eat?
Do you regularly skip breakfast?
Do you ever have a snack attack? And if so, when... Daytime / Evening
What is your favourite snack?
How much do you spend on food per week?
Where do you carry most of your unwanted weight?
Do you take vitamins or any type of nutritional supplements?
How many glasses of water do you drink daily?
How often do you eat fast food per week?
Where are your energy levels daily, on a scale of 1 to 10? (1: low / 10: High)
How often do you exercise per week?
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Your Typical Daily Diet
What time do you usually wake up?
BREAKFAST (Eat & Drink)
AM SNACK (Eat & Drink)
LUNCH (Eat & Drink)
PM SNACK (Eat & Drink)
DINNER (Eat & Drink)
EVENING (Eat & Drink)
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GOALS: WHY do you want to accomplish this? Be as SPECIFIC, DETAILED and VAIN as possible. How do you want your body to look and feel? Do you want more confidence? Do you want to be secure in your own body?
Would you be open to taking a look at how you could make an extra income, without affecting what you're currently doing?
Who referred you or sent you this survey?
On a scale of 1-10 with 10 being the most serious and committed, how committed are you to changing your current lifestyle habits to achieve your goals?
Mobile number
SEND THIS SURVEY ON TO 3 FRIENDS, ONCE THEY COMPLETE IT, YOU'LL RECEIVE A FREE BONUS!
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