Evolve: Comprehensive Wellness Form

Evolve: Comprehensive Wellness Form

Confidential intake to support your health and wellness journey. Please answer what you feel comfortable sharing - your responses help us provide truly personalised care.
Personal Details
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Best way to contact you

Other
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Setting Boundaries

Please let me know what you are happy to discuss with me and topics that feel off limits.
I am comfortable talking about all of the topics listed below.
I am only comfortable talking about these specific topics:

Other
Consent

In addition to your consent here, I will also obtain your verbal consent before doing any soft tissue therapy, manually cueing or assessing you during a session.
I am comfortable with you applying soft tissue therapy, manually cueing and manually assessing all the body parts listed below.
I am only comfortable with you applying soft tissue therapy, manually cueing and manually assessing these specific body parts:

Other
Your Health Details

Please answer the following questions to the best of your knowledge.
Are you currently experiencing or have you recently experienced any muscle or joint pain? If yes, please explain.
Do you have a previous history of injury, pain, or physical limitations with any body parts? If yes, please explain.
Have you ever had surgery? If yes, please explain.
Do you currently or have you ever experienced any of the following? If so, please check the boxes and provide relevant details in the space provided below.

Other
Use this space to provide details on any boxes checked above. Please include when symptoms started/diagnosis happened, any treatment(s), and current status.
Have you been diagnosed (currently or in the past) with any significant medical conditions and/or injuries that you haven’t mentioned yet?
If you answered yes, please check all that apply and explain:

Other
Use the space below to provide details on any boxes checked above.
Are you taking any prescription medications, aside from MHT? Please list names, what it treats, frequency and dosage.
Please list all current supplements, frequency and dosage.
Are you currently on Menopause Hormone Therapy? (MHT/HRT) If so, which ones and dosage.
If not, are you considering MHT or do you have any strong feelings about it one way or another?
Have you had a DEXA scan? A DEXA scan determines your bone density rating.
DEXA T-score (if known)
DEXA diagnosis
If you answered yes, please explain and outline any guidance or instructions provided by your doctor:
Please list you current GP, including contact details, and any complimentary practitioners you are currently working with.
Are you open to me collaborating with your other practitioners as part of your care?
Menstrual & Hormonal Health
Current phase
Are you currently cycling?
Are you experiencing any recent cycle changes? If so, please describe.
If you picked perimenopausal above, how do you know you are in perimenopause?
Are you postmenopausal?
Date of your final cycle.
If you have children, please tell me the number of births, dates and types of deliveries (Vaginal, Cesarean, Assisted (forceps/vacuum))
Did you experience any tearing? If so, what degree?
Any complications with any of the births?
Anything else important to note about your birth history?
Pelvic health details - Have you seen a Pelvic Health Specialist? Are you currently under the care of a Pelvic Health Specialist? If so, have you received a diagnosis?
Motivations & Symptoms
What prompted you to reach out?
What feels most out of sync or different in your body at the moment?
Are you experiencing any of the following symptoms?

Other
What feels most impactful right now? Why?
Exercise History
Current activity level
What does movement currently look like for you?
Exercise history (past 5 years) Do you have any experience with resistance training? If so, please describe.
How do you feel in your body when you move?
Nutrition, Digestion & Metabolism
How would you describe your current approach to eating and nourishing your body?
Have you ever, or are you currently, experiencing any challenges with food?
How do you feel around food right now?
3-Day Food Record - Please log all food intake and times for 3 full days - record here.
Please describe your most common energy level patterns throughout the day - for example, stable, peaks and crashes, low overall, etc.
Sauna & RLT/NIR

Thermotherapy, Red, Infrared and Near-Infrared light therapy. To be answered by those in The Evolve Series. If not in The Evolve Series, skip to the next section.
Do you have any experience with sauna or light therapy? If so, please describe.
Do you have any of the following contraindications to sauna use? Please select all that apply. If none, leave blank.

Other
Do you have any of the following considerations for light therapy (red/near-infrared)?

Other
Sleep & Stress
From 1-10, how would you rate your sleep? 1 being absolutely awful, 10 being brilliant.
What does a typical night look like? Do you have difficulty falling asleep, waking during the night, early waking, restless / light sleep. Please describe.
How would you rate your current stress levels (1–10)? 1=cool as a cucumber, 10=completely overwhelmed by stress
What are your main sources of stress?
How stress shows up in your body?
What are you currently doing to manage your stress levels?
What brings you a sense of energy or fulfilment?
Lifestyle & Support Network
What does a typical day look like for you?
Who do you live with?
What demands most of your time and energy?
What do you do for enjoyment or to switch off?
How would you describe your community or support network?
Please give me some examples of music you enjoy for movement AND music you enjoy for relaxation.
I will create personalised playlists for our sessions together.
Mindset & Relationship to Your Body
How do you currently feel about your body? Has this changed in recent years? How?
What beliefs or frustrations are you holding about this stage of life?
Readiness & Capacity
How ready do you feel to make changes right now? (1–10)
What has helped you stay consistent in the past? What tends to get in the way?
What would you most like to improve or change?
What would success look like for you in the next 3–6 months?
Top priority 1
Top priority 2
Top priority 3
Anything else you’d like me to know that hasn’t been asked?
One final question: What does “feeling like yourself again” actually look like for you?
Disclaimer & Informed Consent
Disclaimer acknowledgement
Signature
Date

MonthDayYear
Date
Should be Empty:

Evolve: Comprehensive Wellness Form

Personal Details

Setting Boundaries

Consent

Your Health Details

Menstrual & Hormonal Health

Motivations & Symptoms

Exercise History

Nutrition, Digestion & Metabolism

Sauna & RLT/NIR

Sleep & Stress

Lifestyle & Support Network

Mindset & Relationship to Your Body

Readiness & Capacity

Disclaimer & Informed Consent