Welcome to Your Personalized Wellness Plan

Thank you for choosing the VIP option to enhance your Life After Cancer journey. This is your first step in creating a custom plan tailored to your unique needs, preferences, and goals. Please complete this form as thoroughly as possible to help us design a plan that supports your physical, emotional, and spiritual wellness.

At Maevora Wellness Collective, we are committed to creating a safe, judgment-free space for you to share your journey. The more open and honest you are with your answers, the better we can tailor your personalized wellness plan to meet your unique needs. Rest assured, all information you provide is strictly confidential and will only be used to create your plan. Your trust means the world to us, and we’re here to support you every step of the way.

Name

First Name

Last Name

Phone

(###)

###

####

Preferred Method of Communication

Age

Height

Weight

Type of Cancer and Stage Diagnosed

Date of Diagnosis

YYYY

Date of Last Treatment

YYYY

Current Health Conditions or Diagnoses (e.g., diabetes, heart conditions, autoimmune disorders)

Any Current Medications or Supplements (please list with dosages)

Known Allergies or Sensitivities (food, medications, environmental)

Current Mobility or Physical Limitations (if any)

How would you describe your daily energy levels?

What is your current sleep routine?

Hours of sleep per night

Sleep quality (Good, Fair, Poor)

How do you currently manage stress? (e.g., yoga, journaling, medication)

How often do you exercise? (Type and frequency)

What does a typical day of eating look like for you?

How many meals/snacks to you consume in an average day?

Preferred foods and beverages

Foods you dislike or avoid

How many ounces of water do you drink daily?

Do you drink alcohol? If yes, how frequently?

Do you use tobacco products? If yes, how often?

Do you use marijuana products? If yes, how often?

How would you rate your current emotional well-being?

Do you engage in mindfulness or meditation practices? If so, how often?

Do you feel connected to a sense of purpose?

What does self-care look like for you currently?

Are there specific spiritual or religious practices that are important to you?

What are your primary wellness goals? (e.g., increased energy, improved diet, reduced stress, better sleep)

What would a successful wellness plan look like to you?

Are there specific areas you’d like to focus on (e.g., nutrition, fitness, mental health, spiritual growth)?

What is one thing you’ve always wanted to try but haven’t yet?

Do you prefer structured routines or flexible plans?

How much time can you dedicate to wellness activities daily?

Do you have access to certain resources, such as a gym, yoga studio, or outdoor space?

Are there specific types of exercise you enjoy or dislike?

Do you have any dietary preferences or restrictions? (e.g., vegetarian, gluten-free)

Do you have a support system in place? (Family, friends, groups, etc.)

Would you like to incorporate your support network into your wellness plan?

Are there people or activities that motivate and inspire you?

Is there anything else you’d like us to know about your journey, challenges, or preferences?

Once you’ve completed the form, we’ll begin creating your personalized wellness plan. Expect to receive your custom plan within 5-7 business days. If you have any questions, don’t hesitate to reach out to us at hello@maevora.com.

Ready for Wellness Answers That Work?

Welcome to Your Personalized Wellness Plan