Zholistic Personalized Health Plan Request Form

Thank you for choosing Zholistic Life to partner with you on your wellness journey!This form helps us understand your current health, lifestyle, and goals so we can design a personalized Zholistic Health Plan that aligns with your body’s unique needs and your faith-centered approach to renewal.

Please answer each question as thoroughly and honestly as possible.The more detail you provide, the more precise and effective your personalized plan will be. Every response helps us tailor recommendations for nutrition, supplements, movement, and lifestyle that best support your goals.

Your information will remain confidential and used only for the purpose of creating your customized plan. Once submitted and payment of $79.99 is received, you will receive a detailed Zholistic Health Plan designed specifically for you within 3 - 5 business days, complete with nutritional guidance, supplement support, meal examples, and a faith-based path toward balance and vitality.

This is your first step toward living with purpose, energy, and alignment — mind, body, and spirit.

SECTION 1: Personal Information

First name

Last name

Birthday

Month

Day

Year

Biological Sex (for health and supplement recommendations):

Male

Female

Prefer not to say

Phone

Preferred Method of Contact:

Phone

Text

Multi-line address

Country/Region

Address

City

Zip / Postal code

SECTION 2: Health & Wellness Goals

Current Height (feet, inches):

Current Weight (pounds)

Goal Weight (pounds)

If other, please share:

What are your top 1–3 health or wellness goals? (Example: weight management, better sleep, improved digestion, increased energy, stress reduction)

What motivated you to request a Zholistic Health Plan at this time?

SECTION 3: Medical & Lifestyle Background

Do you have any current medical diagnoses or chronic conditions?

Are you currently taking any medications?

Are you currently taking any supplements or vitamins?

Do you have any known allergies or sensitivities (foods, medications, or environment)?

Have you recently completed a detox, fast, or cleanse?

Yes

If yes, when and what type?

SECTION 4: Daily Lifestyle & Nutrition

How would you describe your current diet?

Balanced (includes fruits, vegetables, lean protein, whole grains)

Moderate (some healthy choices, but inconsistent)

Processed / Fast-Food Heavy

Plant-Based

Vegan or Vegetarian

Other

List other here:

How much water do you drink daily?

Less thank 4 cups

4-6 cups

7-9 cups

10+ cups

Do you consume caffeinated beverages or energy drinks?

Never

Occasionally

Daily

Type/Brand:

Do you drink alcohol?

Never

Occasionally

Weekly

Frequently

Do you smoke or use tobacco?

Occasionally

Daily

SECTION 5: Movement & Physical Activity

How often do you exercise or engage in physical activity?

Rarely

1-2 times/week

3-4 times/week

5+ times/week

List other here:

Do you have any joint pain, injuries, or mobility concerns that limit your movement?

SECTION 6: Sleep & Stress

Average hours of sleep per night:

Less than 5

5 - 6

7 - 8

Do you wake feeling rested?

Yes

How would you rate your current stress level?

Low

Moderate

High

What are your main sources of stress? (Example: work, finances, relationships, health, etc.)

How do you typically manage stress? (Example: prayer, exercise, music, food, solitude, etc.)

SECTION 7: Mind-Body-Spirit Connection

How important is faith or spirituality in your personal wellness journey?

Very important

Somewhat Important

Not a Focus

Would you like faith-based or scripture reflections included in your plan?

Yes

Are there any mental or emotional habits you want to change or strengthen? (Example: negative thinking, lack of motivation, anxiety, etc.)

SECTION 9: Preferences & Restrictions

Are there any foods you wish to avoid or dislike?

List other here:

SECTION 10: Authorization & Agreement

By submitting this form, I acknowledge that the Zholistic Health Plan is a wellness resource created for educational and lifestyle purposes only. It is not intended to diagnose, treat, or replace medical care.

I confirm that the information provided is accurate and complete to the best of my knowledge.

Signature

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Date Submitted

Month

Day

Year

Thank you for completing your Zholistic Health Plan Request Form.Your submission has been received, and our team will begin reviewing your information to create your personalized mind, body, and spirit wellness plan.

Each plan is carefully crafted to align with your unique goals, lifestyle, and faith journey. You’ll receive your completed plan via email within 3 - 5 business days.

If additional details are needed, a member of the Zholistic Life team will contact you directly.

We’re honored to walk beside you as you take this next step toward renewal, alignment, and lasting transformation.

Personalized Health Plan

$79.99

Your personalized Zholistic Health Plan will be created and delivered once full payment has been received.This ensures that your plan is carefully designed, reviewed, and customized to meet your individual health goals.Payments are non-refundable once the plan has been initiated.

Thank you for valuing the time, research, and expertise invested in every Zholistic Life plan — created to guide you toward balance, vitality, and transformation.

Zholistic Life Foundation

Zholistic Life Health & Wellness

CONTACT

Tel. (336) 290-1322
Wellness@ZholisticLife.com

support@ZholisticLife.com