Nutrition for Healing Program

Nutrition for Healing Program

Nourishing the body Supporting the journey
partnered with Sanara Wellness to create the Nutrition for Healing™ program because we recognized that women facing breast cancer need support that goes beyond financial assistance alone. Treatment can take an enormous toll on the body, mind, and overall well-being, and many women are left feeling exhausted, overwhelmed, and unsure of how to properly nourish themselves during and after treatment. Through this partnership, Pawsitively 4 Pink and Sanara Wellness aim to support the whole woman by providing education, guidance, and realistic nutritional support that can help women feel stronger, healthier, and more empowered throughout their healing journey. Our goal is not perfection — it is helping women regain strength, confidence, and hope one step at a time.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Age
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Please describe your current health and wellness challenges and explain why you are interested in participating in the Nutrition for Healing™ program through Sanara Wellness.
Demographic Information Race/Ethnicity
How did you hear about Pawsitively 4 Pink?
Health & Treatment Information
Are you currently experiencing any of the following?
Do you have any dietary restrictions or food allergies?
Current stage of treatment
Current Medications or Supplements
Wellness & Lifestyle
How motivated do you currently feel to make lifestyle or nutrition changes?
How often do you cook meals at home?
How often do you feel overwhelmed trying to figure out what is “healthy” during treatment?
Current Physical Activity Level
Program Outcome Questions
What are you hoping to gain from this program?
Do you believe nutrition can play a role in healing and recovery?
Optional Open-Ended Questions

These often become powerful testimonials later.
What has been the hardest part of your wellness journey during cancer treatment?
Is there anything else you would like us to know about your situation or goals?
Household Information
Marital Status
Number of Adults in Household
Number of Children in Household
Children ages
Employment & Income
Have you experienced a loss of income due to treatment?
Current Employment Status
Monthly Household Income
Name of company that you work for
How would you describe your current stress level related to finances?
Nutrition for Healing™ Pre-Program Wellness Survey

This survey helps Sanara Wellness better understand how you are currently feeling physically and emotionally before beginning the Nutrition for Healing™ program. Your responses help us measure the impact of the program and improve support for women facing breast cancer.
How would you rate your current energy level?
How would you describe your current eating and nutrition habits?
How often do you feel physically exhausted or fatigued?
How confident do you currently feel about knowing what foods support your health and healing?
How would you rate your overall mental and emotional well-being right now?
How often does stress impact your physical health or eating habits?
How hopeful do you currently feel about improving your overall health and wellness?
How often are treatment side effects affecting your daily life?
How supported do you currently feel in your wellness and healing journey?
What area of your health would you most like to improve through this program?
Thank you for taking the time to complete this survey. Your responses help us better understand your needs and allow us to provide more meaningful support throughout the Nutrition for Healing™ program.
Required Documentation Checklist
Consent & Signature
I certify that the information provided in this application is true and accurate to the best of my knowledge. I understand that submitting this application does not guarantee assistance.
Applicant Signature

Please sign above.
Date

MonthDayYear
Date
Consent & Disclaimer

The Nutrition for Healing™ program is intended to provide educational wellness and nutrition support and is not a substitute for medical advice, diagnosis, or treatment. Participants should continue following the guidance of their medical providers.
Do you agree to participate in the program and its evaluations?
Should be Empty:

Nutrition for Healing Program

Health & Treatment Information

Wellness & Lifestyle

Program Outcome Questions

Optional Open-Ended Questions

Household Information

Employment & Income

Nutrition for Healing™ Pre-Program Wellness Survey

Consent & Signature