First Name

Last Name

Email Address

Phone #

Have you been in a TBN before? Have you been in a TBN before? Yes No

Are you a Body Boutique member? Are you a Body Boutique member? Yes No

Have you ever had a wellness evaluation? Have you ever had a wellness evaluation? Yes No

If yes, with whom?

Have you ever tried the Herbalife products at home? Have you ever tried the Herbalife products at home? Yes No

What are your wellness goals? What are your wellness goals? Weight Management Better Nutrition/Energy & Fitness Digestive Health Heart Health Sports Nutrition Skin Health