| Health Survey |
| Please note that all fields followed by an asterisk must be filled in. |
1. What are you looking for in your search for good health?*
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| 2. If looking for weight management, how much weight are you serious about losing/gaining? | |
3. Do you suffer from any of the following diet related ailments?
(Choose all that apply) | |
| 4. What other diets orweight management programs have you tried in the last 12 months? | |
First Name*
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Last Name*
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E-mail Address*
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State/Prov*
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Zip/Postal Code*
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Country*
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(Optional)
I would like to receive a phone consultation on this telephone number:
between these times: | |
(Optional)
Please post me Herbalife Product Information and Free Sample pack to this address: | |
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