Confidential Consultation Questionnaire

Client Intake Form

  • Your Cholesterol #’s

  • For Women

  • For Men & Women

  • For men

  • For Men & Women

  • Describe a typical breakfast, lunch and dinner:

  • Please consult the list available here.
  • How our consultation services work

    Initial Consultation:

    A free 15 min introductory session, either by interactive audio and video technology, via email or phone. Learn more about Holistic Nutrition for the Whole You, and if we are the right fit for you.

    Programs made for you:

    For First Time Clients, are encouraged to select the Taking Back Control of Your Health package to kick start your journey. Customized programs to fit your needs also available.

    What is Teleconsulting/Telemedicine?

    Teleconsulting/Telemedicine is the delivery of health care services using interactive audio and video technology, where the client/patient and provider are not in the same physical location. During your telemedicine consultation with a provider, details of your medical or health history and personal health information may be discussed through the use of interactive audio, video, and other telecommunications technology.

    Depending on your medical or health history and specific complaint, you may be asked to provide information through other electronic means and verify your identity with a driver’s license or another legal document.

    The telemedicine services you receive are not intended to replace a primary care physician relationship or for prescribing, diagnosing or treatment. You should seek emergency help or follow-up care when recommended or when otherwise needed, and continue to consult with your primary care physician and other health care professionals as recommended.

  • Your Contract with Holistic Nutrition for the Whole You & Fraud Prevention and Security statement.

    • • To access nutrition consulting services, you represent and warrant that you are of legal age to sign a binding contract and possess the legal right and ability, on behalf of yourself or a minor child of whom you are a parent or legal guardian, to agree to these Terms of Use.

    • • You agree to fully, completely, accurately and truthfully provide, including, but not limited to, your name, mailing address, phone number, email and password, which become your ID and credentials.

    • • You agree to prohibit anyone else from using your password and credentials, and you agree to immediately notify Holistic Nutrition for the Whole You of any actual or suspected unauthorized use of your ID or credentials or other security concerns of which you become aware.

    • • At no point will this office or our affiliates retain, store or file credit card information. This information must be presented at the date of service with ID.

    • • Client health information may be used for anonymous research. At no time will personal names, addresses or potentially other sensitive information be used.

    • • Holistic Nutrition for the Whole You may contact you by telephone, mail or email to verify your information. Holistic Nutrition for the Whole You may request details from you, and you agree to provide such details to ensure you have not fraudulently contracted services. If you do not provide this information in the manner requested within 14 days of the request, Holistic Nutrition for the Whole You reserves the right to suspend, discontinue or deny services, until the information is provided by the customer as requested.

    • • This information is for nutritional evaluation based on family history or medically diagnosed health challenges; it is not to be construed or used as a medical diagnosis, treatment or prescriptive. The information presented is intended for educational purposes only and is not designed to be a substitute for professional medical advice, diagnosis, or treatment. We are not liable for any personal injury or mental anguish including death, caused by the use of any information provided by third parties or products you purchase. The information provided is intended as educational, and we do not have any control over how you may choose to use said information. Therefore we cannot be held responsible for your actions.

    • • We do not control the manufacture of dietary supplements, topical products, formulation, or quality of these products, nor do we control any statements written by third parties about the products or products listed. Any information or products you may choose to use requires your responsibility in accordance with the manufacturer's guidelines or those of your health care provider.

    • • All testing is done through third party labs; this office provides you with information about these labs, it is up to you to pursue and purchase the use of their services. Insurance billing requires coding from a recognized medical provider. Holistic Nutrition for the Whole You will not provide you with any said coding for insurance reimbursement.
  • The passcode will be used as proof of identity in all future correspondence and contact.
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Custom plans to help you with your health and nutritional goals.

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