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Home
About Us
Our Team
Loyalty Program
Contraindications
Frequently Asked Questions (FAQ)
Services
Clinical Services
Wellness Services
Beauty And Spa Services
Patient Intake Form
Contact Us
Patient Intake Form
Patient Intake Form
Let's see what we can do for you
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Services
Which holistic services are you interested in?
Body Care Services aimed at improving physical function, addressing pain or tension, and enhancing movement. These therapies focus on muscles, connective tissues, and overall structural alignment.
Clinical Evidence-based or integrative medical therapies designed to treat specific health conditions, improve recovery, and support systemic healing.
Rejuvenation Aesthetic and regenerative services that refresh, restore, and enhance the skin and body’s vitality, promoting a youthful and revitalized appearance.
Relaxation Therapies centered on stress relief, mental clarity, and emotional balance, providing a tranquil environment for mind and body relaxation.
Renewal Holistic services that focus on revitalizing energy, enhancing resilience, and promoting inner balance and well-being for sustainable wellness.
Skincare Treatments tailored to improve skin health and address concerns such as aging, hydration, and pigmentation, emphasizing both professional care and maintenance.
Other
Other
Troy Location
(Required)
Clinic Services
Select All
Ayurvedic
Energetic Systems Maintenance – ESM
Energy Medicine
Holistic
Medical Hypnotherapy
Naturopathic
PEMF – Pulsed Electromagnetic Field
Quantum Resonance Magnetic Analyzer (Biofeedback)
Radio Frequency Electromagnetic Fields (RIFE)
Total Body Modification (TBM)
None
Farmington Location
(Required)
Wellness Center Services
Select All
Alpha Stim Micro-current Therapy
Chakra Energy Balancing
Craniosacral Therapy
HeartMath
Hyperbaric Oxygen Therapy (HBOT)
Iridology
Light Therapy
Migun Bed
Muscle Response Testing (MRT)
Naturopathic Therapy
Pulsed Electromagnetic Field (PEMF)
Quantum Resonance Magnetic Analyzer (Biofeedback)
Reflexology
Sound Therapy
None
Farmington Location
(Required)
Beauty & Spa
Select All
Aveda Services
Esthetics (Skincare)
Facial & Body Treatments
Henna Services
Lash & Brow Services
Make Up Application
Splendor X (Laser Hair Reduction)
TriLift (Non-Surgical Skin Rejuvenation)
Waxing Services
None
Communication
Follow-up communications?
(Required)
Text Message
Email
Phone
How did you hear about us?
(Required)
Friend / Family
Social Media
Search / Advertisement
Other
Medical History
Vaccination History
None
Anthrax
BCG (Tuberculosis)
Cholera
COVID-19 Vaccine
Dengue
DTaP (Diphtheria, Tetanus, Pertussis – Children)
DT (Diphtheria, Tetanus – Without Pertussis)
Ebola
Erysipelas (Rare veterinary-related vaccine)
H5N1 (Avian Influenza)
H7N9 (Avian Influenza)
HepA (Hepatitis A)
HepA-HepB Combo (Hepatitis A and B)
HepB (Hepatitis B)
Hib (Haemophilus Influenzae Type B)
HPV (Human Papillomavirus)
Influenza (Flu)
Influenza (High-Dose) (For adults 65 and older)
IPV (Inactivated Polio Vaccine)
Japanese Encephalitis
Malaria (Prophylactic, not vaccine)
MenACWY (Meningococcal Groups A, C, W, Y)
MenB (Meningococcal Group B)
MMR (Measles, Mumps, Rubella)
MMRV (Measles, Mumps, Rubella, Varicella)
Pneumococcal (PCV13, PPSV23)
Pneumococcal 15-Valent (PCV15)
Pneumococcal 20-Valent (PCV20)
Rabies
Rotavirus
RSV (Respiratory Syncytial Virus)
Shingrix (RZV) (Recombinant Zoster Vaccine – Newer shingles vaccine)
Smallpox
TDAP (Tetanus, Diphtheria, Pertussis – Adults/Boosters)
Tick-Borne Encephalitis
Tetanus (Td) (Standalone booster)
Typhoid
Typhus
Varicella (Chickenpox)
Yellow Fever
Zoster (Shingles) (Older vaccines, replaced by Shingrix)
Other
Other
Do you have any existing medical conditions?
None
Allergic reactions to specific ingredients or products
Arthritis
Asthma
Cancer
Chronic pain conditions
Chronic skin conditions (e.g., severe acne, eczema)
Diabetes
Digestive disorders (e.g., IBS, Crohn's disease)
Epilepsy or seizures
Heart conditions
High cholesterol
Hypertension
Immunocompromised conditions
Kidney disease
Liver disease
Mental health conditions (e.g., depression, anxiety)
Respiratory conditions (e.g., COPD
Stroke
Thyroid conditions
Other
Other
Do you have any allergies?
None
Animals (e.g., cats, dogs) – Allergies to pet dander or saliva.
Bee stings/Insect venom – Allergic reactions to bee, wasp, or ant stings.
Dairy – Includes milk, cheese, and related products.
Dust mites – A common cause of respiratory or skin reactions.
Eggs – Includes egg whites and yolks.
Fish – Includes non-shellfish seafood, such as salmon or tuna.
Gluten – A protein found in wheat, barley, and rye.
Latex – Found in gloves, balloons, and other products.
Mold – Common environmental allergen.
Nuts – Includes tree nuts (e.g., almonds, walnuts) and peanuts.
Penicillin – A common antibiotic.
Pollen – Common allergen from plants and flowers.
Shellfish – Includes shrimp, crab, lobster, and similar seafood.
Soy – Found in soybeans and products like tofu or soy milk.
Sulfa drugs – A class of medications that may cause allergic reactions.
Wheat – An allergy to wheat, separate from gluten sensitivity.
Other
Other
Have you had any surgeries in the past?
No
Appendectomy – Removal of the appendix.
Back surgery – Includes procedures like spinal fusion or discectomy.
Breast surgery – Includes mastectomy or breast augmentation/reduction.
Cataract surgery – Removal and replacement of the eye’s cloudy lens.
Cesarean section (C-section) – Surgical delivery of a baby.
Gallbladder removal (Cholecystectomy) – Removal of the gallbladder.
Heart surgery – Includes bypass, valve replacement, or stent placement.
Hip replacement – Replacement of the hip joint.
Hysterectomy – Removal of the uterus.
Knee replacement – Replacement of the knee joint.
Prostate surgery – Includes prostatectomy for benign or cancerous conditions.
Tonsillectomy – Removal of the tonsils.
Wisdom teeth extraction – Removal of impacted or problematic wisdom teeth.
Other
Other
Do you have any of the following medical implants or devices?
None
Cochlear implant – A hearing device for profound hearing loss.
Defibrillator (ICD) – An implanted device to regulate irregular heart rhythms.
Dental implants – Artificial tooth roots placed in the jawbone.
Insulin pump – A device for continuous delivery of insulin for diabetes management.
Joint replacements – Includes hips, knees, or other joint prosthetics.
Metal implants (e.g., plates, screws) – Used in orthopedic surgeries to stabilize bones.
Pacemaker – A device to regulate abnormal heart rhythms.
Spinal cord stimulator – A device implanted to manage chronic pain.
Stents – Devices placed in arteries or other vessels to maintain flow.
Other
Other
Are you currently taking any medications?
No
Albuterol (Ventolin, ProAir) – Treats asthma or breathing issues by opening airways.
Amlodipine (Norvasc) – Lowers blood pressure and chest pain.
Aspirin (Bayer, Ecotrin) – Used for pain relief, reducing heart attack risk, or preventing blood clots.
Atorvastatin (Lipitor) – Reduces cholesterol and heart disease risk.
Hydrochlorothiazide (HCTZ) – Diuretic for managing blood pressure and fluid retention.
Ibuprofen (Advil, Motrin) – Relieves pain, fever, and inflammation.
Insulin (Multiple brands) – Controls blood sugar in diabetes.
Levothyroxine (Synthroid, Levoxyl) – Treats underactive thyroid (hypothyroidism).
Lisinopril (Prinivil, Zestril) – Manages high blood pressure and heart failure.
Losartan (Cozaar) – Treats high blood pressure and protects kidneys in diabetes
Metformin (Glucophage, Fortamet) – Controls blood sugar in type 2 diabetes.
Metoprolol (Lopressor, Toprol XL) – Manages blood pressure, chest pain, and heart rhythm.
Omeprazole (Prilosec) – Reduces stomach acid for reflux and ulcers.
Prednisone (Deltasone) – Reduces inflammation in various conditions.
Warfarin (Coumadin) – Prevents blood clots in conditions like atrial fibrillation.
Other
Other
Have you taken or are you currently using any of the following medications for skin-related conditions?
No
Accutane (Isotretinoin) – Treats severe acne.
Adapalene (Differin) – A retinoid for mild to moderate acne.
Azelaic Acid (Finacea, Azelex) – Treats acne and rosacea.
Biologics (e.g., Humira, Stelara, Enbrel) – Treats moderate-to-severe psoriasis or autoimmune disorders.
Brimonidine Gel (Mirvaso) – Reduces redness caused by rosacea.
Clindamycin/Benzoyl peroxide (Acanya, Benzaclin) – Combines an antibiotic and antibacterial to treat acne.
Coal Tar – Used for psoriasis and eczema.
Cyclosporine – An immunosuppressant for severe psoriasis.
Dupilumab (Dupixent) – A biologic for moderate-to-severe eczema.
Finasteride (Propecia) – Treats hair loss or hormonal conditions.
Hydroquinone – Lightens dark spots or hyperpigmentation.
Ivermectin Cream (Soolantra) – Treats inflammatory rosacea.
Methotrexate – Treats severe psoriasis or autoimmune skin conditions.
Minoxidil (Rogaine) – Treats hair loss.
Oral antibiotics (e.g., Doxycycline, Minocycline) – Treats bacterial infections associated with acne.
Pimecrolimus (Elidel) – Non-steroidal cream for eczema.
Spironolactone (Aldactone) – Treats acne and hormonal imbalances.
Tazarotene (Tazorac, Avage) – A retinoid for acne and psoriasis.
Topical steroids (e.g., Betamethasone, Hydrocortisone) – Reduces inflammation in skin conditions like eczema.
Tranexamic Acid – Used for melasma or post-inflammatory hyperpigmentation.
Tretinoin (Retin-A) – A retinoid for acne and anti-aging.
Other
Other
Do you currently use or have you previously used any of the following homeopathic medications or remedies?
None
Aconitum Napellus (Aconite) – Commonly used for sudden fever or shock.
Allium Cepa – Used for colds, allergies, or watery eyes.
Antimonium Tartaricum (Antimony Tartar) – For respiratory issues, such as mucus buildup.
Apis Mellifica (Honeybee) – For swelling, stings, or allergic reactions.
Arnica Montana (Arnica) – For bruises, muscle pain, or injuries.
Arsenicum Album (Arsenic Trioxide) – For digestive issues and anxiety.
Baryta Carbonica (Barium Carbonate) – For glandular swellings or developmental delays.
Belladonna – For high fever or inflammation.
Bryonia – For dry coughs, joint pain, or irritability.
Calcarea Carbonica (Calcium Carbonate) – For bone health or slow growth in children.
Carbo Vegetabilis (Vegetable Charcoal) – For digestive issues or bloating.
Causticum – For burns, incontinence, or muscle stiffness.
Chamomilla (Chamomile) – For teething pain or irritability.
Cinchona Officinalis (China Bark) – For fatigue or weakness after illness.
Ferrum Phosphoricum (Iron Phosphate) – For inflammation or early signs of cold.
Gelsemium Sempervirens – For flu-like symptoms or nervous exhaustion.
Graphites (Black Lead) – For skin disorders, such as eczema or dry skin.
Hepar Sulphuris (Calcium Sulfide) – For infections or abscesses.
Hypericum Perforatum (St. John's Wort) – For nerve pain or injuries.
Ignatia Amara – For grief, anxiety, or mood swings.
Ipecacuanha (Ipecac) – For nausea or vomiting.
Kali Bichromicum (Potassium Dichromate) – For sinus congestion or sticky mucus.
Lachesis Mutus (Bushmaster Snake Venom) – For circulatory issues or hormonal imbalances.
Ledum Palustre (Wild Rosemary) – For puncture wounds or insect bites.
Lycopodium Clavatum – For digestive disorders or confidence issues.
Mercurius Solubilis (Mercury) – For mouth ulcers or sore throat.
Natrum Muriaticum (Sodium Chloride) – For colds, migraines, or emotional stress.
Nitricum Acidum (Nitric Acid) – For mouth ulcers or rectal pain.
Nux Vomica – For hangovers, digestive issues, or irritability.
Phosphorus – For respiratory issues or fatigue.
Podophyllum (Mayapple) – For diarrhea or gastrointestinal issues.
Pulsatilla (Windflower) – For hormonal imbalances or emotional sensitivity.
Rhus Toxicodendron (Poison Ivy) – For joint pain or skin rashes.
Ruta Graveolens (Rue) – For tendon or ligament injuries.
Sabadilla – For allergies or hay fever.
Sepia – For hormonal imbalances or menopausal symptoms.
Silicea (Silica) – For skin conditions or expelling foreign objects.
Spongia Tosta (Roasted Sponge) – For dry, barking coughs.
Sulphur – For chronic skin issues or itching.
Symphytum Officinale (Comfrey) – For bone healing or injuries.
Thuja Occidentalis (Tree of Life) – For warts or skin growths.
Urtica Urens (Stinging Nettle) – For burns, hives, or itchy skin.
Other
Other
Do you currently use or have taken any of the following supplements?
None
Aloe Vera – Supports digestion and promotes skin health.
Ashwagandha (Withania somnifera) – An adaptogen used to reduce stress and improve energy.
Astragalus – Enhances immune function and vitality.
Berberine – Supports blood sugar control and cholesterol management.
Black Cohosh – Helps with menopausal symptoms and hormonal balance.
Boswellia (Indian Frankincense) – Reduces inflammation and supports joint health.
Bromelain – A digestive enzyme that supports digestion and reduces inflammation.
Chlorella – A nutrient-dense algae used for detoxification.
Collagen Peptides – Improves skin elasticity and joint health.
Coenzyme Q10 (CoQ10) – Boosts energy production and supports heart health.
Cranberry Extract – Promotes urinary tract health.
Curcumin (Active compound in Turmeric) – Helps with inflammation and antioxidant support.
Dandelion Root – Supports liver function and digestion.
Echinacea – Enhances immune system response.
Elderberry (Sambucus nigra) – Supports immune health during cold and flu season.
Fish Oil (Omega-3 Fatty Acids) – Promotes cardiovascular and brain health.
Flaxseed Oil – A plant-based source of Omega-3 fatty acids for heart health.
Garlic Extract (Allicin) – Supports cardiovascular health and immune function.
Ginger Root (Zingiber officinale) – Aids digestion and helps relieve nausea.
Ginkgo Biloba – Enhances memory and cognitive function.
Glutathione – A powerful antioxidant that supports detoxification.
Green Tea Extract – Boosts metabolism and provides antioxidant benefits.
Hemp Seed Oil – Supports skin hydration and joint health.
Hyaluronic Acid – Improves skin hydration and lubricates joints.
Kava Kava – Promotes relaxation and helps reduce anxiety.
L-Arginine – Supports cardiovascular health and enhances blood flow.
L-Glutamine – Aids gut health and muscle recovery.
L-Theanine – Promotes relaxation and focus.
Lion’s Mane Mushroom – Supports cognitive function and nerve health.
Magnesium Glycinate – Relaxes muscles and improves sleep quality.
Maca Root – Boosts energy and supports hormonal balance.
Melatonin – Helps regulate sleep cycles.
Milk Thistle (Silybum marianum) – Protects liver health and aids detoxification.
Oil of Oregano – Supports immune function and respiratory health.
Olive Leaf Extract – Provides immune support and has antioxidant and anti-inflammatory properties.
Probiotics (e.g., Lactobacillus, Bifidobacterium strains) – Improves gut health and digestion.
Reishi Mushroom – Enhances immune function and reduces stress.
Rhodiola Rosea – An adaptogen that helps with stress and fatigue.
SAM-e (S-Adenosylmethionine) – Supports mood regulation and joint health.
Saw Palmetto – Promotes prostate health and hormonal balance.
Serrapeptase – Reduces inflammation and aids in scar tissue breakdown.
Shilajit – Enhances energy and nutrient absorption.
Spirulina – A nutrient-rich algae that boosts energy and detoxification.
St. John’s Wort – Helps improve mood and manage mild depression.
Turmeric (Whole Root Powder) – Supports general wellness and inflammation management.
Valerian Root
Other
Other
Do you currently use or have taken any of the following vitamins, nutrients or micronutrients?
None
Adenine (Vitamin B4) – A nucleotide essential for DNA and RNA but no longer classified as a vitamin.
Biotin (Vitamin B7) – Supports metabolism and promotes healthy hair, skin, and nails.
Carnitine – Supports energy production by helping transport fatty acids into cells.
Choline – Vital for brain health, liver function, and nerve signaling.
Folate (Vitamin B9, Methylfolate) – Necessary for DNA synthesis, cell growth, and red blood cell formation.
Inositol (Vitamin B8) – Supports mental health, cell signaling, and insulin sensitivity (not officially classified as a vitamin).
NAD (Nicotinamide Adenine Dinucleotide) – A coenzyme derived from Niacin (Vitamin B3) that aids in energy metabolism and cellular repair.
Niacin (Vitamin B3) – Converts food into energy and supports healthy skin and nerves.
Pantothenic Acid (Vitamin B5) – Aids in the production of energy, fats, and hormones.
PABA (Vitamin B10) – Supports skin health and may assist in folate metabolism (not essential).
Pyridoxine (Vitamin B6) – Supports brain health, neurotransmitter production, and immune function.
Riboflavin (Vitamin B2) – Essential for energy production and maintaining healthy skin and eyes.
Salicylic Acid (Vitamin B11) – Often linked to folate metabolism but not classified as an essential vitamin.
Thiamine (Vitamin B1) – Converts carbohydrates into energy and supports proper nerve function.
Vitamin A (Retinol) – Important for vision, immune health, and cell growth.
Vitamin B12 (Cyanocobalamin or Methylcobalamin) – Vital for nerve function, DNA synthesis, and red blood cell production.
Vitamin C (Ascorbic Acid) – An antioxidant that supports immune health, collagen production, and wound healing.
Vitamin D (Cholecalciferol, D3) – Regulates calcium and phosphorus for bone health and supports immune function.
Vitamin E (Tocopherol) – Acts as an antioxidant and helps protect cells from damage.
Vitamin K (K1 - Phylloquinone, K2 - Menaquinone) – Plays a key role in blood clotting and bone metabolism.
Other
Other
Lifestyle, Habits and Social History
How would you describe your overall lifestyle?
Sedentary Minimal physical activity beyond basic daily tasks (e.g., sitting most of the day at work or home, limited exercise). Examples: Desk jobs, primarily seated activities, little to no exercise.
Lightly Active Regular daily movements combined with light exercise or physical activity. Examples: Walking for leisure, light chores, or occasional short workouts (e.g., yoga, stretching).
Moderately Active A combination of daily movements and structured exercise or active hobbies. Examples: Regular walking, jogging, moderate housework, or engaging in sports/exercise 3–5 times a week.
Very Active High levels of physical activity, often involving intense exercise or a physically demanding job. Examples: Intense workouts, professional training, frequent sports, or active physical jobs like construction work or farming.
Other
Other
Do you use any recreational drugs?
None
Cocaine
Intravenous
Marijuana
Other
Other Drugs
Described if you selected other above
Have you smoked or used tobacco products in the past?
Yes
No
Do you consume alcohol?
Never
Rarely Alcohol consumption is infrequent, occurring less than once a month or only on special occasions. Example: A drink at a wedding, holiday party, or rare social event.
Occasionally Alcohol consumption happens periodically, typically a few times a month. Example: A drink during weekend gatherings, dinners, or celebrations.
Frequently Alcohol consumption is regular, occurring multiple times per week or daily. Example: Having drinks with dinner, at social events, or as part of a routine.
Other
Other
Dietary Habits
Diet Type
Select one
Alkaline Diet – Prioritizes foods believed to promote a balanced body pH.
Anti-Inflammatory Diet – Focuses on foods that may reduce inflammation.
Ayurvedic Diet – Based on traditional Indian medicine and tailored to individual body types (doshas).
Blood Type Diet – Recommends foods based on an individual’s blood type (e.g., Type O, A, B, AB).
Carnivore – Exclusively eats animal products.
Dairy-Free – Avoids dairy products.
Flexitarian – Primarily vegetarian but occasionally eats meat.
Fruitarian – Primarily or exclusively consumes fruits, with some nuts and seeds.
Gluten-Free – Avoids gluten-containing foods.
High-Protein Diet – Emphasizes high protein intake from various sources.
Intermittent Fasting – Focuses on eating during specific time windows.
Ketogenic – High-fat, low-carb diet.
Low-Carb – Restricts carbohydrates.
Low-FODMAP Diet – Avoids fermentable carbs to manage digestive issues.
Macrobiotic Diet – Focuses on whole grains, vegetables, and legumes.
Mediterranean Diet – Emphasizes whole grains, vegetables, fruits, and healthy fats.
Omnivore – Eats both plant and animal foods.
Paleo – Focuses on whole foods, lean proteins, fruits, and vegetables.
Paleo-Vegan (Pegan) – A hybrid of Paleo and Vegan diets, emphasizing whole plant-based foods.
Pescatarian – Eats fish but no other meat.
Raw Food – Eats unprocessed and uncooked foods.
Vegan – Does not eat any animal products.
Vegetarian – Does not eat meat but may eat animal products like dairy and eggs.
Whole30 – A 30-day elimination diet focusing on whole, unprocessed foods.
Other
Other
Meal Frequency
How many meals or snacks do you typically eat in a day?
None
1 Meal
2 Meals
3 Meals
4 or More Meals
Snacks (Eaten between meals or as meal replacements.)
Other
Other
How much water do you typically drink in a day?
Select all that apply
None
Less than 1 liter
1 - 2 liters
2 - 3 liters
More than 3 liters
Other
Other
What are your hydration habits?
Select all that apply
None
Drink primarily water
Drink flavored water or electrolyte drinks
Drink soda or sugary beverages
Drink Carbonated/Sparkling Water
Drink coffee or tea
Drink sports drinks
Other
Other
Hydration habits
Fruits & Vegetables
e.g., daily servings or favorite types
Proteins
e.g., meat, fish, beans, nuts
Grains
e.g., whole grains, rice, bread
Food allergies or dietary restrictions
Please specify
What is your primary health goal related to your diet?
Enhance Overall Wellness A general goal of improving physical and mental well-being by eating a balanced, nutrient-dense diet.
Improve Digestion Focused on enhancing gut health, reducing bloating, or managing digestive conditions (e.g., IBS, acid reflux).
Improve Mental Clarity and Focus Aims to support cognitive function and reduce brain fog through targeted nutrients.
Improve Skin Health Focused on achieving clearer, more hydrated, or youthful-looking skin through dietary choices.
Increase Energy Levels Seeks to optimize nutrition to combat fatigue and maintain consistent energy throughout the day.
Manage a Health Condition Focused on addressing or managing a specific health issue through diet (e.g., diabetes, hypertension, high cholesterol).
Muscle Gain Aims to increase muscle mass through higher protein intake and balanced nutrition.
Support Immune Health Focused on strengthening the immune system through vitamins, minerals, and balanced nutrition.
Weight Loss Focused on reducing body weight by managing calorie intake and improving nutritional quality.
Other
Other health goals
Emotional and Mental Well-Being
Stress Level Assessment
How would you rate your current stress level?
On a scale of 1-10 (1 = minimal stress, 10 = extreme stress)
What factors contribute to your stress?
None
Environmental Factors Stress from external surroundings (e.g., noise, commute, pollution, or lack of personal space).
Financial Concerns Stress caused by money management, debt, or financial insecurity (e.g., paying bills, saving for the future).
Health Issues Stress related to personal or a loved one's physical or mental health conditions.
Life Transitions Stress related to major life changes (e.g., moving, changing jobs, becoming a parent, or retirement).
Personal Relationships Stress arising from interactions with family, friends, or partners (e.g., conflict, expectations, or lack of support).
Time Management Stress from feeling overwhelmed or not having enough time to accomplish tasks and responsibilities.
Work-related Stress caused by job responsibilities, workplace environment, or career challenges (e.g., deadlines, workload, conflicts).
Other
Other factors
How do you typically cope with stress?
None
Connecting with Nature Spending time outdoors, such as hiking, gardening, or enjoying natural settings, to feel grounded and rejuvenated.
Distraction Activities Using TV, movies, video games, or other forms of entertainment to temporarily take the mind off stress.
Exercise Engaging in physical activities such as walking, running, yoga, or gym workouts to release tension and improve mood.
Hobbies or Creative Outlets Engaging in enjoyable activities like painting, cooking, reading, gardening, or playing music.
Journaling or Writing Processing emotions by writing thoughts, feelings, or gratitude in a journal.
Meditation or Mindfulness Practicing relaxation techniques such as deep breathing, meditation, or mindfulness exercises to calm the mind.
Professional Help Seeking guidance from therapists, counselors, or mental health professionals.
Spending Time with Loved Ones Finding comfort and support by being with family, friends, or pets.
Unhealthy Coping Mechanisms (e.g., overeating, substance use) Acknowledging potentially harmful ways of managing stress.
Other
Other ways
Holistic Wellness Goals & Treatment Preferences
What are your reasons for seeking holistic treatments?
Unsure
General Well-being To maintain overall health, balance, and vitality through preventive or supportive care.
Hormonal Balance and Support To address hormonal imbalances affecting energy, mood, or reproductive health.
Improved Sleep Quality To enhance sleep patterns, reduce insomnia, or achieve more restful sleep.
Mental Health and Emotional Well-being To reduce anxiety, depression, or emotional stress through supportive therapies.
Pain Management To alleviate chronic or acute pain in areas like muscles, joints, or nerves.
Stress Relief To manage and reduce stress levels through relaxation techniques and therapies.
Weight Management Support To assist with achieving or maintaining a healthy weight through holistic approaches.
Other
Other
What specific goals would you like to achieve through our wellness and spa services?
Unsure
Body Relaxation To release physical tension, reduce stress, and achieve a sense of calm and comfort.
Detoxification To cleanse the body of toxins and improve overall well-being.
Enhanced Circulation To promote better blood flow and oxygen delivery throughout the body.
Improved Skin Health To address skin concerns such as hydration, aging, or texture for a more radiant appearance.
Mind-Body Balance To achieve harmony between physical health and mental well-being.
Pain Relief To alleviate chronic or acute pain through therapeutic techniques.
Skin Rejuvenation To revitalize and refresh the skin, improving tone, texture, and elasticity.
Stress Reduction To manage and lower stress levels through relaxation therapies.
Other
Other
Sensitivity to Scents or Aromas
Unsure
None
No Sensitivity You do not experience any discomfort or adverse reactions to scents or aromas.
Mild Sensitivity You may occasionally notice slight discomfort or prefer lighter fragrances but generally tolerate scents well.
Strong Sensitivity You frequently experience adverse reactions, such as headaches, nausea, or irritation, and avoid fragrances entirely.
Strong Sensitivity You frequently experience adverse reactions, such as headaches, nausea, or irritation, and avoid fragrances entirely.
Other
Other
What is your preference for pressure during applicable services?
Unsure
No Preference
Light Pressure Gentle and soothing pressure, ideal for relaxation and sensitivity to touch.
Medium Pressure Balanced pressure, providing both relaxation and therapeutic benefits without being too intense.
Firm Pressure Deep and intense pressure, targeting specific areas of tension or discomfort for therapeutic relief.
Specific Areas of Focus
Please check all areas where you are experiencing discomfort or would like to focus on during your treatment
Do you experience muscle tension or discomfort in any of the following areas?
Unsure
None
Arms Tension, weakness, or soreness in the biceps, triceps, or forearms.
Back Discomfort in the upper, mid, or lower back, often due to posture or strain.
Feet Issues such as soreness, plantar fasciitis, or tension in the arches or soles.
Head Headaches, migraines, or tension in the scalp, temples, or base of the skull.
Legs Cramps, soreness, or stiffness in the thighs, calves, or hamstrings.
Neck Stiffness, pain, or restricted movement in the cervical region.
Shoulders Tightness, knots, or discomfort in the shoulder muscles.
Other
Other
Do you experience joint issues in any of the following areas?
Unsure
None
Ankles Instability, pain, or stiffness in the ankle joint.
Elbows Pain, stiffness, or limited movement, such as tennis elbow or golfer’s elbow.
Hips Discomfort, stiffness, or restricted mobility in the hip joint.
Knees Pain, swelling, or discomfort in the knee joint due to strain, injury, or arthritis.
Neck Stiffness, pain, or limited movement in the cervical joints.
Shoulders Joint pain, limited mobility, or conditions like frozen shoulder.
Wrists Discomfort or weakness in the wrist joint, including carpal tunnel symptoms.
Other
Other
Do you experience any skin or circulatory concerns?
Unsure
None
Bruising Frequent or unexplained bruises, possibly indicating fragile blood vessels or circulation issues.
Cold Extremities Persistent coldness in hands, feet, or other extremities, even in warm conditions.
Cracked or Thickened Skin Cracks, calluses, or thickened areas, often on hands or feet.
Discoloration Skin discoloration, such as redness, paleness, dark patches, or cyanosis (bluish skin tone).
Dry or Flaky Skin Persistent dryness or peeling, potentially due to dehydration or skin conditions.
Hot or Red Skin Areas of skin that feel warm or appear red, possibly due to inflammation or infection.
Itchy Skin (Pruritus) Persistent itching, with or without visible rashes.
Open Sores or Ulcers Non-healing wounds or ulcers, especially on legs or feet.
Poor Circulation Symptoms like numbness, tingling, or coldness in specific areas (e.g., hands, feet).
Rashes or Irritations Includes redness, itching, or irritation in specific areas.
Skin Sensitivity Increased sensitivity to touch, temperature, or certain products.
Swelling (Edema) Unusual swelling in areas like the legs, feet, or hands.
Varicose or Spider Veins Noticeable or uncomfortable veins in the legs or other areas.
Other
Other
Mental and Emotional Well-being
Unsure
None
Concentration and Memory – Difficulty focusing or forgetfulness.
Mood Changes – Persistent sadness, irritability, or emotional instability.
Sleep Quality – Difficulty falling or staying asleep, or feeling rested.
Stress – Chronic stress, anxiety, or burnout.
Other
Other
Digestive Health
Unsure
None
Bloating or Gas – Persistent or occasional discomfort.
Constipation – Infrequent or difficult bowel movements.
Diarrhea – Frequent or loose stools.
Food Sensitivities or Intolerances – Reactions to specific foods (e.g., dairy, gluten).
Heartburn or Acid Reflux – Burning sensation in the chest or throat.
Other
Other
Energy Levels
Unsure
None
Fatigue – Persistent tiredness or lack of energy.
Low Stamina – Difficulty maintaining physical or mental activity for extended periods.
Midday Slumps – Feeling exhausted during the afternoon.
Other Energy Concerns – Specify any unique symptoms.
Other
Other
Immune System Health
Unsure
None
Allergies – Seasonal or environmental allergies.
Autoimmune Concerns – Symptoms linked to autoimmune conditions.
Frequent Colds or Infections – Recurring illnesses or slow recovery.
Other
Other
Neurological Concerns
Unsure
None
Dizziness or Vertigo – Feeling unsteady or lightheaded.
Headaches or Migraines – Persistent or occasional head pain.
Numbness or Tingling – Unexplained sensations in hands, feet, or other areas.
Other
Other
Hormonal Health
Unsure
None
Hot Flashes or Night Sweats – Symptoms of hormonal imbalance.
Menstrual Irregularities – Irregular, painful, or absent periods.
Thyroid Concerns – Symptoms like weight changes, fatigue, or temperature sensitivity.
Other
Other
Physical Fitness and Mobility
Unsure
None
Postural Issues – Slouching, uneven shoulders, or back pain from poor posture.
Range of Motion – Difficulty moving joints or performing specific actions.
Weakness – Muscle weakness or reduced strength.
Other
Other
Lifestyle and Environmental Factors
Unsure
None
Environmental Sensitivities – Reactions to pollution, chemicals, or allergens.
Hydration Levels – Struggles with drinking enough water.
Nutrition – Poor eating habits or imbalanced diet.
Sleep Hygiene – Poor sleep habits or disruptive environment.
Other
Other
Pain Management
Unsure
None
Acute Pain – Recent injuries or pain from physical activity.
Chronic Pain – Long-term discomfort in any area of the body.
Other
Other
Overall Wellness Goals
Unsure
None
General Health Maintenance – Preventive care and balance.
Improved Mobility – Better range of motion or flexibility.
Stress Relief – Focus on reducing stress and promoting relaxation.
Weight Management – Support for losing, gaining, or maintaining weight.
Other
Other
Comfort Level with Different Therapy Modalities
Rate from 1-10, 1 = minimal, 10 = extreme
Acupuncture/Acupressure
1
2
3
4
5
6
7
8
9
10
Energy Healing
1
2
3
4
5
6
7
8
9
10
Massage Therapy
1
2
3
4
5
6
7
8
9
10
What is your level of experience with holistic treatments?
Unsure
No Experience You have not tried any holistic treatments before.
Limited Experience You have tried one or two holistic treatments but are not very familiar with them.
Some Experience You have tried a few holistic treatments and have a general understanding of them.
Extensive Experience You regularly use holistic treatments and are well-versed in different modalities.
Open to Trying New Modalities You are curious and willing to explore holistic treatments, regardless of past experience.
If applicable, please provide additional details about the areas mentioned above, and let us know if there is anything you would like to ask, discuss, or explore with us.
(Feel free to elaborate on specific symptoms, concerns, or experiences to help us better understand your needs. Your input is valuable to us. If you have nothing to add, simply write 'N/A' or 'Not Applicable.')
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Our Philosophy
We offer alternative, complementary, integrative, and holistic therapies designed to support the physical, emotional, mental, and spiritual aspects of well-being. Our goal is to help individuals recognize, release, and restore balance in these areas.
Our environment is intentionally calm and caring, fostering a sense of safety and belonging for all clients, including those with heightened sensitivities.
Cancellation Policy
To ensure the best experience for all our clients, we kindly request at least 24 hours' notice if you need to cancel or reschedule your appointment. This allows us to accommodate other clients who may be waiting for an appointment.
Cancellations made with less than 24 hours' notice may be subject to a cancellation fee, which will be outlined at the time of booking.
No-shows or same-day cancellations may result in a charge of up to the full appointment cost.
By scheduling an appointment, you acknowledge and agree to this policy. We appreciate your understanding and cooperation as we strive to provide exceptional service to all our clients.
I consent to receive holistic treatments and agree to disclose accurate medical history to the best of your knowledge?
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