‍ ‍ New Client Intake Form

Please complete this form before your first appointment.
The information you share will help us better understand your health history, current areas of discomfort, and overall wellness goals, so we can provide more thoughtful and personalized support.

If there is anything you are unsure about, simply answer to the best of your knowledge.

Personal Information

Full Name :
Age :
Date of Birth :
Sex :

  • Male

  • Female

  • Prefer not to say

Email Address :
Phone Number :

Work and Daily Activity

Previous Occupation :
Length of Time in That Role :
Current Occupation :

Optional note:
Please include any work or daily routine that involves prolonged sitting, standing, lifting, repetitive movement, or physical strain.

Health History

Health History (in chronological order)
Please list any significant health conditions, injuries, diagnoses, or physical concerns in chronological order.

Surgical History

Have you ever had surgery?

  • Yes

  • No

If yes, please list the surgeries and approximate dates.

Your Main Concern

What symptom, discomfort, or condition would you most like to improve at this time?
Please describe your main concern as clearly as possible.

How long have you been experiencing this concern?

  • Less than 1 week

  • 1–4 weeks

  • 1–3 months

  • 3–6 months

  • 6–12 months

  • More than 1 year

What types of care or treatment have you tried previously?
Examples may include massage therapy, chiropractic care, physical therapy, acupuncture, medication, stretching, exercise, rest, or other wellness approaches.

Current Pain or Discomfort Level

What is your pain or discomfort level right now?
Please rate your current level on a scale from 0 to 10.

0 = No pain or discomfort
10 = Severe pain or discomfort

Areas of Pain or Other Symptoms

Where are you currently experiencing pain, tension, or other symptoms?
Please describe the area or areas as specifically as possible. For example: neck, right shoulder, lower back, left hip, jaw, upper back, or both knees.

How would you describe what you are feeling?

  • Sharp

  • Dull

  • Aching

  • Tightness

  • Burning

  • Tingling

  • Numbness

  • Stiffness

  • Other

Additional Information

Is there anything else you would like us to know before your appointment?

Consent and Acknowledgment

Please check to confirm the following:

  • I confirm that the information I have provided is accurate to the best of my knowledge.

  • I understand that Holistic Balance Therapy is a wellness-based service and is not a substitute for medical diagnosis, medical treatment, or emergency care.