Download Checklist and Physician's Consent Form
Please submit this form in advance of your first WC 360° session.
* Indicates required fields
* Select the number, on a scale of 0 to 10 (0 never and 10 always) that represents your experience.
Sore or stiff muscles or joints
Heartburn, acid reflux
Fatigue, lack of energy
Food cravings (sugar, fat, salt etc.)
Eat to reduce stress
Lack of concentration
Depression, unpleasant mood
* Which best describes how you perceive your health?
* How much control do you feel you have over your health? (On a scale from 0-10, 0 being no control and 10 being total control)
A low-fat, whole foods, plant-based diet emphasizes fruits, vegetables, and starches (beans, lentils, and whole, intact grains) and, at the same time, limits or eliminates animal products (all meats, including chicken and fish, dairy, and eggs) and highly refined foods, such as white flour, refined sugar, and oil. About 80% of calories come from carbohydrates, 10% from fats, and 10% from protein.
* How closely does your diet resemble a WFPB diet? (0-10, 0 being not at all resembling a WFPB diet and 10 being strictly resembling.)
* How many minutes per week do you engage in exercise?
* On a scale of 0-10 (with 0 showing the least stress and 10 the most) how would you rate the stress level in your life?
Consider the wellness goals you want to accomplish in the course of the 7-week program. Please choose from the following and indicate the specifics of your goals. For example, if weight loss is one of your goals, check weight loss and indicate how many pounds you would like to lose on the line that follows.
34 Bay Street Suite 205 | Mailing: P.O. Box 1141, Sag Harbor, NY 11963 | (631) 329-2590 | firstname.lastname@example.org