Patient Wellness

Name*

Email*

Injury & Physical Concerns

Do you Currently have an injury or an ongoing weakness?*

How Long has this been bothering or irritating you?*

Would you like to receive a free consultation? *
YesNo

Services & Support

Are there any services we offer that interest you or that you feel you may benefit from?*
NaturopathyChiropracticPhysiotherapyRemedial MassageAcupunctureExercise RehabilitationNutritional SupportStress/Nervous System Support

Planning Your Care

Many patients find it difficult to plan ahead. This questionnaire helps create structure and continuity in your health journey so we can provide the most appropriate care for your needs.

Realistically, how many sessions per year do you feel would help keep you in good working order?*
1-23-56-1010+

Energy Levels

How would you rate your average daily energy? (0 = very low, 10 = excellent)*
12345678910

Do you find it difficult to get going in the morning?*
YesNo

Do you feel sleepy or flat after meals?*
YesNo

Nervous System & Sleep

These symptoms are closely linked to nervous system regulation and overall stress load.

Do you experience any of the following?*
AnxietyLow mood / mild depressionInsomnia

On average, how many nights per week do you sleep well?*
0-12-34-56-7

Digestive Health

Do you experience any of the following?*
BloatingIrritable Bowel Syndrome (IBS)Reflux / HeartburnPoor appetiteConstipation

If yes, how often do symptoms occur?*
Occasionally1-2 times per week3–5 times per weekMost days

Body Composition & Strength Goals

Would you like support with any of the following?*
Weight managementMuscle developmentStrength & conditioningBody composition optimisation

Hormonal Health

Hormones influence energy, mood, sleep, weight, digestion, and overall wellbeing.

For Women:

Do you experience any of the following?*
Irregular cyclesPainful periodsHeavy or prolonged bleedingPMS or cycle-related mood changesAcne or skin flare-upsEndometriosis or PCOSPerimenopausal or menopausal symptoms

Do Symptoms worsen around your cycle? (fatigue, mood, anxiety)*
YesNo

Are you currently*
Trying to conceivePostpartumNavigating Menopause

For Men:

Do you experience any of the following?*
Low energy or motivationReduced muscle mass or strengthIncreased body fatReduced libidoPoor exercise recoveryMood changes or irritabilitySleep disturbances

Have you noticed a change in vitality or resilience over recent years?*
YesNo

Skin Health

Do you experience any of the following skin conditions?*
PsoriasisEczemaSeborrheic dermatitisAcneRosaceaOther skin conditions

How often do these symptoms flare up?*
OccasionallyRarelyMonthlyWeeklyMost days

Final Step

Once completed, this questionnaire will be personally reviewed by Bryan Carver. Bryan will then arrange a complimentary phone consultation to discuss your current health situation and help guide you towards the most appropriate care pathway if needed.