Please enable JavaScript in your browser to complete this form.
-
Step
1
of 14
Name
*
First
Last
Next
Can you please provide your age?
Under 18
Under 18
18-25
26-35
36-45
46-55
56-65
66 and above
Next
How would you describe your current physical health?
Excellent
Excellent
Good
Fair
Poor
Not sure
Next
Are you experiencing any specific symptoms or discomfort? If yes, please select from the following options:
*
Fatigue
Headaches/Migraines
Digestive issues
Joint/muscle pain
Sleep disturbances
Respiratory problems
Mood swings/Emotional instability
Skin conditions
Hormonal imbalances
Memory/concentration issues
Other
Next
Have you been diagnosed with any medical conditions? If yes, please select from the following options:
Diabetes
Hypertension
Thyroid disorder
Asthma
Allergies
Autoimmune disorder
Mental health condition
Neurological condition
Digestive disorder
Other
Next
Are you currently taking any medications? If yes, please select from the following options:
*
Yes, I am taking medication(s) for a diagnosed condition
Yes, I am taking medication(s) for a diagnosed condition
Yes, I am taking over-the-counter medications
Yes, I am taking herbal remedies/supplements
No, I am not taking any medications
Next
How would you rate your current stress level?
*
Low
Low
Moderate
High
Very high
Next
What Are the mental health challenges you are currently facing ? If yes, please select from the following options:
Anxiety
Depression
Stress
Emotional trauma
Bipolar disorder
Overthinking
Other
Next
How would you describe your energy levels throughout the day?
*
High
High
Average
Low
Next
Are you facing any challenges in your personal or professional life that are affecting your overall well-being? If yes, please select from the following options:
*
Work-related stress
Relationship issues
Family issues
Financial difficulties
Loss or grief
Life transitions
Traumatic events
Chronic stress
Other
Next
Have you tried any other treatments or therapies for your condition? If yes, please select from the following options:
*
Acupuncture
Chiropractic care
Massage therapy
Physical therapy
Counseling/therapy
Herbal remedies/supplements
Homepathy
Allopathy
Meditation/mindfulness
Yoga
Other
Next
Are you open to exploring holistic or alternative therapies to address your concerns?
*
Yes I am interested as my well being is priority
Yes I am interested as my well being is priority
No but want to explore/known
Not sure but i am
Not sure but want to explore further
Next
What are your specific goals or desired outcomes from enrolling in our services? Please select from the following options:
*
Pain relief
Stress reduction
Improved sleep quality
Enhanced emotional well-being
Better digestion
Increased energy levels
Overall wellness and balance
Improved focus and concentration
Getting relief from my prolonged illness
Being more mindfulness
Other
Next
Is there any additional information you would like to share that might help us better understand your situation and provide tailored care?
*
Submit
Back to Home