Free Assessment

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You Deserve 2 Be Healthy! 6-Week Course

This is a strictly confidential Assessment which will be viewed and assessed only by Certified Wholistic Nutritionists, Christen Kaplan and Elizabeth Inman. Your health is our top priority. We carefully evaluate your Assessment to make sure that you are a good candidate for this program.

First Name *

Last Name *

Email Address *

Phone

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

Please type Yes or No

High Blood Pressure? (yes or no) *

Heart Disease (yes or no) *

High Cholesterol (yes or no) *

Stroke (yes or no) *

Insulin Dependent (yes or no) *

Type 2 Diabetes (yes or no) *

Kidney disfunction (yes or no) *

Cancer (yes or no) *

Respiratory disease (yes or no) *

Stomach Ulcer (yes or no) *

Acid Reflux (yes or no) *

Irritable Bowel Syndrome (yes or no) *

Constipation (yes or no) *

Loose Bowels (yes or no) *

Anorexia (yes or no) *

Bulimia (yes or no) *

Binge Eating (yes or no) *

Malnutrition (yes or no) *

Osteoporosis (yes or no) *

Metabolic Syndrome (yes or no) *

Hyper or Hypo -Thyroid (yes or no) *

Parkinson’s Disease (yes or no) *

Multiple Sclerosis (yes or no) *

Auto Immune Disease (yes or no) *

COPD (yes or no) *

Seizures or fainting (yes or no) *

Sinus issues (yes or no) *

Sleep Apnea (yes or no) *

Eczema or Psoriasis (yes or no) *

Arthritis (yes or no) *

Rheumatoid Arthritis (yes or no) *

Allergies (yes or no) *

Headaches (yes or no) *

Nervous Disorder (yes or no) *

Anxiety Disorder (yes or no) *

Depression (yes or no) *

Bipolar Disorder (yes or no) *

Memory loss (yes or no) *

Glucose intolerance (yes or no) *

Lactose intolerance (yes or no) *

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

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PLEASE CONTACT

Christen Kaplan
christen@loveawholisticlife.com

Elizabeth Inman
elizabeth@loveawholisticlife.com