Zholistic Personalized Health Plan Request Form

Welcome to Zholistic Life Health & Wellness.

This form is the first step in creating your personalized Zholistic Health Plan. The information you provide will help me understand your current health, lifestyle, and wellness goals so that your plan can be thoughtfully designed around your specific needs.

Each plan is created individually and may include guidance for nutrition, lifestyle habits, movement, supplement support, and faith-centered encouragement designed to help restore balance and support your overall well-being.

Please answer each question as honestly and thoroughly as possible. The more detail you provide, the more precise and effective your personalized plan will be.

All information shared in this form will remain confidential and will only be used for the purpose of preparing your Zholistic Health Plan.

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:

How long have you been experiencing the concerns you selected above?

Less than 6 months

6–12 months

1–3 years

More than 3 years

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?

Yes

If yes, please list the medications and what they are prescribed for.

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?

Do you have any allergies:

Yes

If yes, list and explain:

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:

Describe a typical day of eating (breakfast, lunch, dinner, snacks).

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 others here:

If other, please explain:

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 during the night?

Yes

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 scripture reflections or faith-based encouragement 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 8: Preferences & Restrictions

Are there any foods you wish to avoid or dislike?

List other here:

Are you currently taking any supplements or herbal products?

Yes

If yes, list them and approximate dosage.

List other here:

SECTION 10: Authorization & Agreement

I understand that I should consult my physician before making significant dietary, supplement, or lifestyle changes

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

After submitting this form and completing payment, please allow 3–5 business days for your personalized Zholistic Health Plan to be prepared.

Your completed plan will be delivered to the email address you provided.

Each plan is carefully developed based on the information you submit so that the recommendations reflect your health goals, lifestyle, and overall wellness needs.

One Time Investment

$149