New Client Paperwork - Evolve A Centre for Optimal Living

1Intro & Personal Info

2Family Info

3History and Current Lifestyle

Evolve Centre for Optimal Living | 20261 E. Ocotillo Rd. Ste 114 Queen Creek, AZ 85142 | Tel: (480)987-0899

The Evolve Difference

At Evolve, we allow your nervous system, which is home to the intelligence that created you, to connect to areas in your body that are storing past and present stress causing your body to express signs and symptoms. As your nervous system begins to process through these stress patterns, you will notice a shift in your physical, emotional and mental state of being. Overtime, this process will allow you to express your full potential and transcend the current disease model of health.

To learn more about Evolve a Centre for Optimal Living and our approach to health, you can book an initial visit on our website or attend a free Optimal Living Seminar.

Welcome to Evolve Centre for Optimal Living!

Lifelong health and vitality is our birthright. Few of us know how we lose it and how to get it back. At Evolve Centre, we have an innovative 5 Pillar approach dedicated to helping you and your entire family express optimal health and healing. Physical, chemical, emotional and mental experiences can accumulate on a daily basis, interfering and challenging your expression of life. This results in aches, pains, and disease, physically, mentally and emotionally. This journey will begin with Pillar 1, restoring optimal nerve flow between your brain and body. By gently removing the interference to your potential with tonal adjustments, your body will begin to heal and reorganize from the inside-out and realize a greater expression of life. Knowledge about you will help in understanding who you are, why you are coming to Evolve Centre, what you are expecting and how we may best assist you towards living optimally. Please take a couple of minutes to document your vital information. If you have any questions, please do not hesitate to ask our staff. Evolve a Centre for Optimal Living is pleased to serve your family. We are committed to empowering all of you to express your full life potential so you may experience the highest expression of health, well being and optimal living.
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone
Email
Date of Birth
MM slash DD slash YYYY
Occupation
How were you referred to Evolve a Centre for Optimal Living?
What is your level of commitment to yourself, your life and journey to Optimal Living?
- High
- Medium
- Low

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Marital Status
- Single
- Married
- Divorced
- Widowed
Name of Partner
Do you have Children?
- Yes
- No
Please list names and date of birth for each of your children
Are any of your children living at home?
- Yes
- No
Is there anything about your nerve system and spine we should know about?

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At Evolve Centre for Optimal Living, we transform peoples lives with the 5 Pillars of Optimal Health.
1. Optimal Nerve Flow
2. Optimal Nutrients & Minerals
3. Optimal Mindset
4. Optimal Biomechanics & Movement
5. Optimal Stress & Toxin Reduction
We begin this journey with restoring Optimal Nerve Flow.
What brings you to Evolve Centre today? Looking at the 5 Pillars of Optimal Health above, what else would you like to receive from your care in this office? (Pillars 2-5)
History of physical stress, trauma or challenges:
The trauma and stress of life is present in all humans (acknowledged or not). Have you had a challenging birth (or delivery), car accident(s), sports injuries, falls, repetitive injuries, etc.…?
Quality of Nutrition (breakfast, lunch and dinner):
Do you eat junk food, skip meals, diet, etc.? Are you a vegetarian, vegan, raw, macro, meat eater? What are your nutritional goals?
History of chemical stress, trauma or challenges:
Chemicals invade our body every second. Our body’s ability to deal with or dispose chemicals is directly related to our expression of life force. Are you challenged with asthma, allergies, chemical addictions, toxicity, medication use, previous overdose or poisoning, environmental toxins?
History of emotional stress, trauma or challenges:
Our expression of health, healing and life is greatly influenced by our emotional well-being. Have you been through a difficult divorce/break-up, stressful job, school, family life or any other major change/challenge?
Movement:
Do you exercise, how often?
Fluid Intake:
What do you drink (alcohol, coffee, tea, cow’s milk, diet-soda, etc. and how often?)
Water Intake
(How many glasses a day?)
What type of work do you do or how do you spend your days?
Is it a high or low stress environment and/or experiences?
Level of satisfaction with career?
Do you have a positive or negative mindset when it comes to life, explain?
Medicine:
(over the counter drugs, prescription, recreational, herbal & nutritional supplements): Your body is always working towards homeostasis (balance). Drugs may destroy balance by either depressing innate intelligence (your body’s intelligence) or tricking it into excitement. Either way, it is not natural, and directly affects how our body heals. List ALL outside – in drugs, current or past.
Any other information about you, that you feel is relevant to transforming your health?
Phone
This field is for validation purposes and should be left unchanged.

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Live a happier, healthier life.

EVOLVE CENTRE FOR OPTIMAL LIVING,
QUEEN CREEK

HOURS

Live a happier, healthier life.

EVOLVE CENTRE FOR OPTIMAL LIVING, QUEEN CREEK

HOURS

EVOLVE CENTRE FOR OPTIMAL LIVING,
QUEEN CREEK