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 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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