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FOR PHYSICAL, MENTAL AND SPIRITUAL HEALTH

FOR PHYSICAL, MENTAL AND SPIRITUAL HEALTH

Weight Loss

Christen Kaplan Wholistic Nutritionist Weight Counselor

Interview with Christen Kaplan

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Enjoy our Educational Blog

Nutrition

Embrace nutrition as the foundation to your health.

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Weight Loss

Discover the educated approach to healthy, lasting weight loss.

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Health

Be empowered to take back your health.

Lifestyle

Learn the dance between a healthy lifestyle and nutrition.

News/ Media

Events, Video, and Press

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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 *YesNo

Heart Disease *YesNo

High Cholesterol *YesNo

Stroke *YesNo

Insulin Dependent *YesNo

Type 2 Diabetes *YesNo

Kidney disfunction *YesNo

Cancer *YesNo

Respiratory disease *YesNo

Stomach Ulcer *YesNo

Acid Reflux *YesNo

Irritable Bowel Syndrome *YesNo

Constipation *YesNo

Loose Bowels *YesNo

Anorexia *YesNo

Bulimia *YesNo

Binge Eating *YesNo

Malnutrition *YesNo

Osteoporosis *YesNo

Metabolic Syndrome *YesNo

Hyper or Hypo -Thyroid *YesNo

Parkinson’s Disease *YesNo

Multiple Sclerosis *YesNo

Auto Immune Disease *YesNo

COPD *YesNo

Seizures or fainting *YesNo

Sinus issues *YesNo

Sleep Apnea *YesNo

Eczema or Psoriasis *YesNo

Arthritis *YesNo

Rheumatoid Arthritis *YesNo

Allergies *YesNo

Headaches *YesNo

Nervous Disorder *YesNo

Anxiety Disorder *YesNo

Depression *YesNo

Bipolar Disorder *YesNo

Memory loss *YesNo

Glucose intolerance *YesNo

Lactose intolerance *YesNo

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

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.

Please do not fill in this field.

Get Your Free Assessment

We'll be glad to help

PLEASE CONTACT

Christen Kaplan
christen@loveawholisticlife.com

Elizabeth Inman
elizabeth.inman@iwd-diagnostics.com

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