Balance and Goals Assessment

First Name *

Last Name *

Email *

Phone *

Date of birth *

Gender *

Male

Femail

Please name the city you reside in. *

Currently our program is only available in our practice, we are based in Pretoria. Would you be able to attend appointments at our premises. *

Yes

No

By completing this evaluation form, you acknowledge and agree to the following:

Purpose: This evaluation is intended to assess mental and emotional factors that may influence your weight loss journey as part of the Holistic 360 program. It is not a diagnostic tool and does not replace professional psychological or medical treatment.
Voluntary Participation: Participation in this evaluation is entirely voluntary, and you may choose not to answer any questions you are uncomfortable with. You can withdraw from the evaluation at any time without affecting your enrollment in the program.
Confidentiality: All information provided will be kept strictly confidential and used solely for the purpose of tailoring your program. Your data will not be shared with third parties without your explicit consent, except as required by law.
Non-Diagnostic Nature: This evaluation is not intended to diagnose, treat, or manage any mental health conditions. If significant concerns are identified, you may be referred to a qualified mental health professional for further support.
Data Security: Your responses will be stored securely and handled in accordance with applicable privacy laws (e.g., POPIA, GDPR). Please ensure the accuracy of the information you provide.
Consent to Use Information: By proceeding, you consent to the collection and use of your responses to enhance your personalized program within the scope of the Holistic 360 offering.

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What we offer:

💡 Discover What Drives You
With our Balance & Goals Assessment, you’ll uncover the mental and emotional factors that impact your journey. This powerful step ensures we align your mindset, habits, and goals to create a personalized roadmap to success.

🧬 DNA Analysis: Tailored to Your Unique Genetics
Your one-time DNA analysis reveals the secrets of your metabolism, food sensitivities, and genetic predispositions, allowing us to tailor your program for maximum results. This is not a one-size-fits-all approach—this is your unique blueprint for success.

⚖️ Body Composition Analysis: Beyond the Scale
Understand more than just your weight. Our advanced analysis measures muscle mass, fat percentage, and hydration levels, giving us the tools to monitor your progress with precision.

🩺 Expert Medical Supervision
Your journey is guided by professionals, starting with comprehensive medical consultations. From injectables to personalized recommendations, every step is monitored to ensure safety and effectiveness.

💉 Medical Injectables:
Doctor-prescribed treatments work with your body to regulate appetite, boost metabolism, and accelerate weight loss. These cutting-edge solutions are designed for noticeable, sustainable results.

🍽️ A Nutrition Plan That Works for You
We simplify healthy eating with a personalized nutritional plan tailored to your preferences, lifestyle, and health needs. No more guesswork—just delicious, satisfying meals that fuel your transformation.

💊 Comprehensive Supplementation for Optimal Results
We ensure your body gets everything it needs to thrive, with a carefully curated selection of supplements:

Minerals to support metabolism, energy, and bone health.
Gut Health Supplements to enhance digestion and nutrient absorption.
Vitamins to fill nutritional gaps, boost immunity, and energize your body.
Hormonal Aid to optimize balance, mood, and weight management.
Antioxidants to protect your body from stress and enhance recovery.

🥤 Convenient Protein Meal Replacements
On busy days, our protein meal replacements ensure you stay nourished and satisfied, all while supporting muscle maintenance and fat loss.

🏋️‍♀️ Custom Fitness Guidance
Whether you’re new to exercise or a seasoned pro, we create a fitness plan designed to fit your lifestyle and keep you moving toward your goals.

📈 Ongoing Support & Monitoring
Your success is our priority. With regular progress monitoring and coaching, you’ll stay motivated, overcome obstacles, and celebrate milestones every step of the way.

📊 Personal Online Goal Tracking (Coming Soon)
Stay connected to your journey with our upcoming goal-tracking platform, designed to keep you motivated and inspired in real time.

Most programs focus only on weight loss—but Holistic 360 focuses on you. This isn’t just about shedding kilograms; it’s about gaining confidence, energy, and a healthier, happier life.

Invest in yourself today and experience the difference. This isn’t just another weight loss program—this is your complete transformation.

We’re excited to help you achieve your goals with the Holistic 360 program. Once your survey is complete, one of our specialists will review your responses and contact you to discuss the next steps.

Select Next to complete your assessment

Section 5: Motivation and Readiness for Change

On a scale of 1 to 10, how motivated are you to lose weight? *

What are your primary reasons for wanting to lose weight? (Check all that apply) *

What do you see as the biggest challenges to your weight loss journey? *

How confident are you in your ability to stick to a weight loss plan? *

Section 1: Sleep and Fatigue

How many hours of sleep do you typically get per night? *

Less than 4 hours

4–6 hours

6–8 hours

More than 8 hours

Do you feel well-rested when you wake up? *

Yes

No

Have you ever been diagnosed with a sleep disorder (e.g., insomnia, sleep apnea)? *

Yes

No

If yes, please provide details

Section 7: General Questions

Describe how you feel about your current weight and body image. *

Is there anything else you would like to share that could help us better understand your psychological or emotional health? *

Weight loss with

Dr. Hanlie

Hello there,

I'm Dr. Hanlie, and I'm thrilled to welcome you to Holistic Life Institute!

In South Africa, we're facing a challenge with obesity rates that are among the highest globally, with more than 20 million overweight adults.

But here's the excellent news: positive change is within reach.

If you want to shed that extra weight healthily and sustainably or infuse more energy into your life, you're in the right place.

At Holistic Life Institute, we're dedicated to assisting you on your journey.

Our approach is different—we believe in tackling the root causes of obesity, not just the surface- level symptoms.

With our guidance, you'll be empowered to make lasting changes to your eating habits and overall well-being.

Are you ready to embrace a healthier you?

If the answer is yes, then go ahead and click that button to schedule your appointment.

Let's embark on this transformative journey together!

Click to Make an Appointment

Quick links

Alternative Weight Loss

Address

644 Beagle rd, Garsfontein, Pretoria

Call

087 802 6873

Email

[email protected]

WhatsApp

061 581 4804

Disclaimer:

Information on this page is for all intended purposed guidelines only and should not be regarded as medical advice, condition diagnosis or treatment advice.

For medical advice, consult your doctor.

Balance and Goals Assessment

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