You Deserve 2 Be Healthy!

6-Week Course

Love A Wholistic Life
Client Assessment Form

First Name *

Last Name *

Email Address *

Phone

Have you ever been diagnosed or experienced any of the following?

Please select Yes or No

High Blood Pressure *YesNoDo you have high blood pressure?

Heart Disease *YesNoDo you have heart disease?

High Cholesterol *YesNoDo you have high cholesterol?

Stroke *YesNoHave you had a stroke?

Insulin Dependent *YesNoAre you insulin dependent?

Type 2 Diabetes *YesNoDo you have Type 2 Diabetes?

Kidney disfunction *YesNoDo you have kidney disfunction?

Cancer *YesNoHave you been diagnosed with cancer?

Respiratory disease *YesNoDo you have respiratory disease?

Stomach Ulcer *YesNoHave you had a stomach ulcer?

Acid Reflux *YesNoDo you have acid reflux?

Irritable Bowel Syndrome *YesNoDo you have Irritable Bowel Syndrome?

Constipation *YesNoDo you have Constipation?

Loose Bowels *YesNoDo you have loose bowels?

Anorexia *YesNoHave you had anorexia?

Bulimia *YesNoHave you had bulimia?

Binge Eating *YesNoHave you had binge eating?

Malnutrition *YesNoHave you had malnutrition?

Osteoporosis *YesNoHave you been diagnosed with osteoporosis?

Metabolic Syndrome *YesNoHave you been diagnosed with Metabolic Syndrome?

Hyper or Hypo -Thyroid *YesNoDo you have Hyper or Hypo -Thyroid?

Parkinson’s Disease *YesNoHave you been diagnosed with Parkinson’s Disease?

Multiple Sclerosis *YesNoHave you been diagnosed with Multiple Sclerosis?

Auto Immune Disease *YesNoHave you been diagnosed with an Auto Immune Disease?

COPD *YesNoHave you been diagnosed with COPD?

Seizures or fainting *YesNoHave you experienced seizures or fainting?

Sinus issues *YesNoHave you experienced sinus issues?

Sleep Apnea *YesNoHave you been diagnosed with sleep apnea?

Eczema or Psoriasis *YesNoHave you had Eczema or Psoriasis?

Arthritis *YesNoDo you have arthritis?

Rheumatoid Arthritis *YesNoDo you have Rheumatoid Arthritis?

Allergies *YesNoDo you suffer from allergies?

Headaches *YesNoDo you have headaches?

Nervous Disorder *YesNoDo you have a nervous disorder?

Anxiety Disorder *YesNoDo you have an anxiety disorder?

Depression *YesNoDo you suffer from depression?

Bipolar Disorder *YesNoHave you been diagnosed with Bipolar Disorder?

Memory loss *YesNoHave you suffered from memory loss?

Glucose intolerance *YesNoDo you have glucose intolerance?

Lactose intolerance *YesNoDo you have lactose intolerance?

If you answered yes to any of the previous questions, please explain.

Please answer Yes or No to the following questions.

1. Do you have a hard time falling asleep at night? *YesNoSometimes

2. Do you experience heartburn or acid reflux at night? *YesNoSometimes

3. Do you get up to use the bathroom more than once a night? *YesNoSometimes

4. Do you engage in physical activity outside of work? *YesNoSometimes

5. Do you use tobacco products including cannabis? *YesNoSometimes

6. Do you drink alcohol? *YesNoSometimes

How many drinks do you consume weekly? *

7. Do you have a history of drug abuse or use recreational drugs? *YesNo

8. Do you eat out more than 3 times a week? *YesNoSometimes

9. Do you use alternative modes of transportation? (walking, stairs, or biking) *YesNoSometimes

10. Do you prefer sedentary activities instead of physical activities? *YesNoSometimes

11. Have you noticed a decrease of interest in activities you use to really enjoy? *YesNoSometimes

12. Do you have enough energy to sustain yourself throughout the day? *YesNoSometimes

13. Do you feel well rested when you awake in the morning? *YesNoSometimes

14. Are your five senses acute? Sight, smell, touch, taste, and hearing? *YesNo

15. Do you often experience feelings of sadness or hopelessness? *YesNo

16. Do you experience intense sense of panic or difficulty catching your breath? *YesNoSometimes

17. Do you experience headaches, migraines, or ringing in your ears? *YesNo

18. Have you ever had a stroke? *YesNo

19. Do you snore or do you have tendency to hold your breath while sleeping? *YesNoSometimes

20. Do you experience extreme mood changes? *YesNoSometimes

21. Are you currently going through menopause? *YesNo

22. Are you pregnant? *YesNo

23. Do you suffer from abnormal or extremely painful periods? *YesNoSometimes

24. Have you ever tried to diet or go on a nutritional program before? *YesNo

25. Do you have an aversion to eating fruits and vegetables? *YesNo

26. Are you receiving medical treatment at the present time or in the last 6 months? Please explain. *

27. Are there any medical conditions or reasons not listed in this document that we should be aware of that could affect your nutritional program? If yes, please explain. *

28. Are you currently taking any prescription medications, vitamins, or supplements? *YesNo

28b. If yes, for each, please list Medication, Dosage, Reason

29. Are you taking prescription blood thinners? *YesNo

Height

Weight

Disclaimer

Love a Wholistic Life Inc. and their employees are NOT doctors. Any information given is not a substitute for professional medical advice or consultations with healthcare professionals. Our nutritional program should be discussed with your doctor. Information on this questionnaire is considered private and confidential and is ONLY used for nutritional evaluation purposes. Your information will not be shared with anyone outside of Love A Wholistic Life Inc. Certified Holistic Nutritionist.

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What is the You Deserve 2 Be Healthy! Program?

Intensive Online 6-Week Group Course

You Deserve 2 Be Healthy! is a powerful weight management program with all the tools, education and personal coaching you need to be successful and live life at your best. Certified Holistic Nutritionists, Christen Kaplan, and Elizabeth Inman developed the program with a passion to educate and help people achieve true, lasting heath. They have used this program working with hundreds of clients and their physicians, supporting patients diagnosed with obesity, type 2 diabetes, cardiovascular disease and other medical conditions that improve with proper nutrition and lifestyle choices.

The results have been profound.
Those who have fully complied with the program achieved 100% success rate!*

Now, the You Deserve 2 Be Healthy! Program is available to you as an intensive online 6-Week Group Course. The proprietary online course is specifically designed for people with, (or are at risk for) medical pathologies associated with being overweight. Weight issues for participants range from obese to clinically severe obesity.

With all the mutual support, accountability and insights of a group format, the program also includes creating individualized nutrition and health-style plans, based on each person’s unique body, medical history, lifestyle, goals and mindset. You have all the benefits and dynamics of a group, with the individualized attention of one-on-one coaching.

How Does the Program Work?

THE PROGRAM INCORPORATES TOOLS FOR:

Nutrition
Stress Management
Education
Regaining Your Confidence
Maintaining Your Control

The structure of this program is very specific. The 6-week course incorporates tools for nutrition, stress management, education, and tools that help you regain your confidence and control. Every tool is important and has been designed to work hand in hand with each other to make you successful in taking back your health.

This is NOT A DIET. It is an effective program that incorporates self-discipline and accountability with a nutritional basis that focuses on nutrient-dense foods as the main source of nutrients important for supporting your digestive track and other vital organs. The You Deserve 2 Be Healthy! program has a strong educational foundation. We believe that knowlege is power. And we empower you with the knowledge you need. We do not simply tell you what to do, but educate you along the way, so that you fully understand why and how each food and lifestyle choice affects your health and vitality.

Christen and Elizabeth educate you throughout the 6-week program, incorporating self-discipline and accountability with a personal nutritional plan that focuses on nutrient-dense foods proven to be beneficial to your body. Their caring, expert guidance and motivation provide you with the direction and tools you need to be successful in achieving the goals you set for yourself. Education is the foundation to the program, giving you the knowledge to feel confident in the food choices you make, not only now - but for a lifetime.

This is NOT ABOUT DIETING! It's about changing the very way you think about food.

Here's What You Can Expect from the Program:

Assessments for physical, medical, emotional and mental fitness.
Weekly live online video instruction with group discussion and downloadable course notes.
Weekly online structured course materials and video.
Nutritional program
Daily Journal entries
Homework assignments
Openness to learning meditation and the importance of meditation for stress management
Task to help master your ability to take control of your schedule and eating program
Accountability for open and consistent communication.

Please note that your commitment to open communication and transparency is a very important factor in your success on this program.

For your convenience, we provide our comprehensive, proprietary Assessment Tool at your fingertips! This holistic assessment is free and completely confidential. It is the first step in your You Deserve 2 Be Healthy! journey and provides the information needed to determine how we can best help you achieve true, lasting health.

You Deserve 2 Be Healthy!
6-Week Course

Take our Free Assessment to find out if this is the program for you!