Zuva Women's Wellness Enrollment Assessment
Please complete this assessment to help us tailor your wellness journey. Have your details and health information ready.
Your Details
Full name
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First Name
Middle Name
Last Name
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
WhatsApp number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email address
example@example.com
Occupation / employer
Where You Are Right Now
What best describes your current menstrual stage?
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Still having regular periods
Periods becoming irregular
No period for less than 12 months
No period for more than 12 months (menopause)
Not sure
Age when periods became irregular or stopped
Are you currently on Hormone Replacement Therapy (HRT)?
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Yes
No
Not sure
Your Health Background
Do you have any of the following?
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Heart attack or stroke in the last 6 months
Uncontrolled high blood pressure
Severe osteoporosis with a recent fracture
Active cancer or cancer treatment in the last 12 months
None of the above
Are you currently under the care of a doctor for any chronic condition?
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Yes
No
Please briefly describe the chronic condition(s)
Any injuries or physical conditions we should know about before the Movement Assessment?
Your Goals/What you want to achieve
What are your main goals? (Pick up to 4)
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Lose weight and change body composition
Build strength and fitness
Improve energy and reduce fatigue
Better sleep
Support for mood and mental health
Understand what is happening in my body
Feel confident and strong again
Reduce my risk of osteoporosis or heart disease
In your own words, what would success look like for you in 3 months?
Practical
How did you hear about Zuva?
*
Please Select
WellWoman Clinic referral
Doctor or specialist referral
Friend or family
Social media
Simuka Wellness website
Other
Preferred session time
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Early morning (5–7am)
Morning (8–10am)
Midday (10am-12pm
Afternoon: 2pm-4pm)
Evening(4-8pm)
Other
Is there anything else you would like Taku/Simuka Wellness to know before the Movement Assessment?
Your Energy and Stress
How would you describe your energy levels on a typical day?
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I wake up exhausted before the day begins
I start okay but crash by midday
My energy is unpredictable
I am running on caffeine and adrenaline
I cannot remember the last time I felt energetic
What is your main source of stress right now?
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Financial pressure
Work and career
Children and family
My health and body
Relationships
Caring for parents
All of the above
How do you handle stress most days?
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It is manageable
It is always there in the background
It is overwhelming
I have numbed myself to it and just keep going
Your Eating and Weight
How would you honestly describe your eating right now?
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I eat well and feel good
I eat whatever is available — no time to think
I skip meals then overeat
I use food for comfort
I am trying but nothing works for my weight
I do not know what I should be eating anymore
Where is your biggest concern with your weight?
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Unexplained weight gain
Fat around my abdomen specifically
I have given up trying
My weight affects my confidence
I care more about energy than weight
What has stopped you from prioritising your health until now?
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Did not know where to start
Every programme was wrong for me
Could not afford it
No support from family
Always put everyone else first
The economic situation makes it hard to justify
Did not think anything would work
I am done making excuses — I am ready
Your Time and Readiness
How much time can you realistically commit to your wellness each week?
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I genuinely have no idea where I would find the time
I could carve out 2 to 3 hours if it was structured
I have tried before and lost motivation
Time is not the problem — I need the right structure
I am ready to prioritise this and make it work
What would it mean for you if in 3 months your energy was restored, your weight was moving in the right direction, and you felt like yourself again?
Your Programme Choice
Which Zuva programme are you interested in?
ZUVA START · $80/month — 2x per week Tuesday & Thursday evenings. Movement sessions plus nutrition group workshop every 2 months. Great starting point.
ZUVA BUILD · $120/month — 3x per week Monday, Wednesday & Friday. Movement plus nutritionist and psychologist group sessions every 2 months. Progress check at 3 months.
ZUVA COMPLETE · $150/month — 3x per week prime time slots. Individual nutritionist and psychologist sessions monthly. DEXA scanning. Full six-pillar programme. The complete Zuva experience.
I am not sure yet — I would like to discuss with Taku first
All programmes begin with a $50 Movement Assessment and Nutrition Consultation. You can always upgrade your tier as your journey progresses.
Consent
Consent Statement
I confirm and agree
*
I confirm and agree
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