Peace Balance Wellness Profile

WELCOME TO PEACE & BALANCE

This form helps us understand your wellness goals, sensitivities, and current state so we can create a session that truly supports you. Your information is confidential and used only to personalize your care.

If you have any questions while completing this form, feel free to reach out.

wellness@peacebalanceholistic.com
- Date
- Full Name
  
  First NameLast Name
- City, State, Country (if not USA)
- E-mail
- Phone Number/Text
  Format: (000) 000-0000.
- Emergency Contact
  
  First NameLast Name
- Emergency Contact #
  Format: (000) 000-0000.
- Birth Date
  
  MonthDayYear
- What are your main wellness goals (up to 2)?
  
  Other
- Have you experienced Ayurveda, Massage or Energy Work before?
  Yes / No (If yes, please elaborate on your experience)
- Are there any areas of your body you'd prefer we avoid or focus on more during your sessions?
- Are there any health concerns you'd like us to be aware of to ensure your best experience?
  If yes, please list or input "none".
- Do you have any sensitivities, injuries, or conditions that may affect your comfort during sessions?
  If yes, please list or input "none".
- Are you currently taking medications, supplements, or herbal remedies that you'd like us to be aware of for your wellness experience?
  If yes, please list or input "none".
- Are you pregnant or postpartum?
- What are you most interested in exploring:
  
  Other
- Please share any additional details about your wellness goals or intentions for your journey with us.
- Additional information you would like to share?
- How did you hear about this Peace & Balance Holistic Center?
  
  Other
- If referred by someone, please let us know who to thank.
- Oils and mixtures are organic food grade. Are you allergic to any plants/grains/herbs that you are concerned about for treatments? These will not be digested but applied topically.
  Lisa or N/A
- Do you have any daily activities (such as work, study, or caregiving) that impact your physical or mental well-being?
  If yes, please list or input "none".
- ONLY FILL OUT THE SECTIONS RELEVANT TO YOU
- Do you prefer silence, mantras, soft music, or conversation during treatments?
- Please list or include any oils, herbs or natural scents you prefer to avoid.
  i.e. palo santo, sage, essential oils, etc.
- Have you worked with any of the following practitioners or systems before? (Check all that apply)
  
  Other
- What treatments or approaches have you explored before?
- Are you currently following any specific wellness practices or lifestyle routines?
- Ayurvedic Treatments
- What treatments are you considering?
  
  Other
- Characteristics
  
  Select the one that best describes you over your lifetime.
- My frame:
- My weight throughout my lifetime:
- Most of my life my skin has been:
- My hair has always been typically:
- Generally, my joints are:
- Most of my life my sleep, I describe my sleep as follows:
- Interactions In The World
- Describe your energy level:
- Describe how you respond to challenges and stress:
- Describe your mood :
- Describe your speech:
- Describe how people perceive you:
- Describe your memory:
- Describe your temperature preferences:
- Describe your disposition:
- Describe your hunger:
- Describe your digestion:
- Describe your walking style:
- What are you interested in?
  
  Other
- Should be Empty:

ONLY FILL OUT THE SECTIONS RELEVANT TO YOU

Ayurvedic Treatments

Characteristics

Interactions In The World