20-Minutes Wellness Consultation Form
A Wellness Consultation is a 20-minutes session facilitated by our Holistic Health Coach for you to get an idea on how our various offerings at Balance Health can help your recovery, healing and maintenance. Our holistic approach will help you identify the best treatments for your mind, body, and spirit. We are committed to helping you jumpstart and optimize your wellness!
BASIC INFORMATION
Name
First Name
Last Name
Email
*
example@example.com
Birthday
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Month
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Day
Year
Date
WhatsApp Number (Please include Country Code)
*
Age
Gender
Male
Female
Prefer not to say
Country of Residence
Occupation
Work Industry
Have you checked our website (www.balancehealth.com.hk)?
*
Yes
No (kindly check our website to familiarize yourself with our offerings before the consultation)
Would you like your appointment to be in-person or virtual?
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In-person
Virtual
How did you hear about us?
*
Social Media
Google Search
Online Publications
Referral
Other
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HEALTH & WELLNESS INFORMATION
What are your main health and wellness concern/s?
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Fertility
Stress & Anxiety
Sleeping Conditions
Immunity
Indigestion (IBS, Water Retention, etc)
Weight Loss
Hormone Imbalance
Pain Management
Skin Conditions
Personal Development
Other
Any serious illnesses/hospitalizations/injuries?
How is the quality of your sleep?
Excellent
Good
Fair
Poor
What is your stress level? (5 represents Super Stressed & Burnout and 1 means Not Stress at all)
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Do you take any supplements or medications? Please list down.
Allergies or Sensitivities? Please Explain briefly.
Any healers, helpers, or therapies with which you are involved? Please list.
How you currently using natural alternative medicine to support your health & wellness?
What type of treatment(s) would you be most interested in? Can choose more than one.
*
TRADITIONAL CHINESE MEDICINE(consultation, Acupuncture, Cupping, Moxibustion)
BODY WORK (Physiotherapy, Chi Nei Tsang, massage, Osteopathy)
ENERGY WORK (Reiki, Craniosacral, Kinesiology, Yuen method)
MENTAL & EMOTIONAL TREATMENTS (Hypnotherapy, EFT)
SPIRITUAL WORK(Akashic Records, Shamanic Healing)
COACHING & PSYCHOTHERAPY (Life coaching)
WOMEN’S HEALTH
(for men, please skip this section)
Are your periods regular?
Yes
No
How many days is your flow?
How frequent?
Painful or symptomatic? Please explain.
Reached or approaching menopause? Please explain.
Birth Control History
Have you experienced Yeast or Urinary Tract Infections? Please explain.
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Your Wheel of Life – a Holistic Assessment of your Life
The Wheel of Life is a multi-dimensional tool that helps us to identify what is important in life , where we stand today and what our objectives should be. Using a scale of 1-10 on the wheel, mark both where you are now for each dimension and where you would like to be in one year time. (10 being the highest and 1 being the lowest)
HEALTH: How do you feel physically? Do you have any known health risks or chronic health issues?
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Where you are right now?
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Where you would like to be in one year?
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FOOD & NUTRITION: How healthy is your diet?
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Where you are right now?
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Where you would like to be in one year?
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EXERCISE: Do you take time for exercise? Do you find simple ways to incorporate more physical activity into your daily routine? How healthy is your diet?
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Where you are right now?
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Where you would like to be in one year?
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SLEEP: Do you have enough sleep and how is your sleep quality?
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Where you are right now?
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Where you would like to be in one year?
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EMOTION: Do you often experience positive feelings such as joyfulness, peace, love or do you often experience negative feelings such as anger, anxiety, fear, guilt?
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Where you are right now?
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Where you would like to be in one year?
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RELATIONSHIP: How are your relationships with family/ friends/ partners?
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Where you are right now?
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Where you would like to be in one year?
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SOCIAL LIFE : Do you feel a strong connection with friends, community, and/or other social groups?
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Where you are right now?
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Where you would like to be in one year?
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CAREER : Are you happy in your career? Are you positively challenged by your work? Do you feel supported in personal / professional growth?
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Where you are right now?
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Where you would like to be in one year?
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LEARNING & PERSONAL GROWTH : Do you invest time into learning new things and to expand your knowledge and continuously grow yourself?
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Where you are right now?
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Where you would like to be in one year?
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FINANCIAL : Are you happy with your financial situation? Do you feel financially abundant, stable and secure?
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Where you are right now?
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Where you would like to be in one year?
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SPIRITUALITY : Do you take the time to think about where you personally find meaning, connection and value? Do you take the time to seek meaningful connection with something bigger than yourself?
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Where you are right now?
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Where you would like to be in one year?
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CREATIVITY : Does creative expression come easily and often? Do you actively explore / express your creativity?
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Where you are right now?
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Where you would like to be in one year?
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Anything else you would like us to know?
What would you like to achieve from the support of Balance Health?
*
Data Privacy & Confidentiality
Information given on this Wellness Consultation is completely voluntary and the data collected are treated with utmost confidentiality.
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