Health Consultation - Let us help you!
Let us assist you in selecting the nutritional and/or personal care products that may help you. All information submitted will remain private and confidential.
1.
What are you looking for in your search for good health?
Weight Loss
Health Improvements
Weight Gain
Skin Improvements
Weight Maintenance
2.
If looking for weight management, how much weight are you serious about losing/gaining?
Weight to Lose / Gain:
kilos
pounds
stones
Your Current Weight:
kilos
pounds
stones
Your Height:
feet/inches
cm
Your Age:
years
3.
Do you suffer from any of the following diet related ailments? (choose all that apply)
Acne
Allergies
Arthritis
Asthma
Bronchitis
Burns
Cancer
Candida
Cellulite
Cholesterol
Chronic-Fatigue Syndrome
Circulatory
Colitis
Constipation
Crohns Disease
Depression
Diabetes
Digestive
Diverticulitis
Eczema
Fibromyalgia
Gall-Stones
Gas
Gout
Headaches
Heartburn
Hepatitis
Hiatus-Hernia
High-BP (Hypertension)
Hyperactivity (ADD or ADHD)
Hypoglycemia
IBS (Irritable-Bowel Syndrome)
Joints
Kidney-Stones
Low-Energy
Lupus
MS (Multiple Sclerosis)
Menopause
Menstrual
Migraines
Muscle-Tension
Osteoporosis
PMS (Premenstrual Syndrome)
Pain
Poor Health
Respiratory
Sleeping-Disorders
Spasms
Stress
Surgery-Recovery
Thyroid
Triglycerides
Ulcers
Urinary/Bladder
Varicose-Veins
Weak Immune System
Yeast-Infections
4.
If required, check the boxes that best describe your skin. (select those that apply)
Dry / Sensitive
Normal / Combination
Oily
Fine dry lines around eyes and mouth, dehydration lines on face.
Slightly oily sheen on T-zone area - Not extreme.
Oily sheen on T-zone area and cheeks.
Cheek area is dull, dry, taut.
Drier cheek area.
Enlarged pores and blackheads evident.
Skin is very sensitive to sun, wind and pollution.
Occasional pimples and spots.
Pimples and spots frequent.
5.
Please enter the following contact information.
Name:
Email Address:
Phone - Day:
(please include full area code)
Phone - Evening:
Postal Address:
(we can send information via mail, if required)
Town / City:
State or Area:
Zip / Postal Code:
Country:
Argentina
Armenia
Aruba
Australia
Austria
Belarus
Belgium
Bolivia
Bosnia
Botswana
Brazil
Bulgaria
Canada
Chile
China
Colombia
Costa Rica
Croatia
Cyprus
Czech Republic
Denmark
Dominican Republic
Ecuador
El Salvador
Estonia
Finland
France
Georgia
Germany
Ghana
Greece
Guatemala
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Ireland
Israel
Italy
Jamaica
Japan
Kazakhstan
Korea
Latvia
Lebanon
Lesotho
Lithuania
Macau
Macedonia
Malaysia
Mexico
Moldova
Mongolia
Namibia
Netherlands
New Zealand
Nicaragua
Norway
Panama
Paraguay
Peru
Philippines
Poland
Portugal
Romania
Russia
Serbia
Singapore
Slovak Republic
Slovenia
South Africa
Spain
Swaziland
Sweden
Switzerland
Taiwan
Thailand
Trinidad & Tobago
Turkey
Ukraine
United Kingdom
United States
Uruguay
Venezuela
Vietnam
Zambia
Not listed
Please indicate the best day / time to contact you:
Contact Option 1:
(e.g. Weekdays, Morning 9am - 12pm)
Option 2:
Option 3:
Would you like to receive our product newsletter?
7.
Are there any additional comments you wish to add to aid our evaluation of your health needs?
8.
Please submit your results.
Your contact consultant is:
HERBALFORHEALTH
Herblife Online Shop
For Information:
info@herbalforhealth.co.in
For Complain:
complain@herbalforhealth.co.in
ITPB ROAD, HOODI Circle, WHITEFIELD
Bangalore
,
Karnataka
,
560048
India
+91-7676112244
Herbalife Products
,
Herbalife Weight Loss
,
Herbalife Weight Gain
,
Herbalife Personal Care
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