New-Client Intake | Ensō Therapeutic Wellness

1. Personal Details

Full name *

Preferred name

Date of birth *

Pronouns

Email *

Mobile *

Home address

Occupation

How did you hear about the practice?

2. Emergency Contact

Name

Relationship

Phone

3. Reason for Your Visit

What brings you to the practice today? Please describe your main concern in your own words. *

How long has this been present?

How would you rate it now? (0–10)

What relieves it? What makes it worse?

What would a meaningful improvement look like for you?

4. Medical History

Tick anything that applies, current or past. Add detail in the notes box if helpful.

Notes / additional conditions

Past surgeries, hospitalisations, or significant injuries (with dates if possible)

5. Medications & Supplements

Please list all current prescription medications, over-the-counter medicines, supplements, and herbal remedies.

Allergies (medication, food, environmental, oils)

6. Lifestyle & Wellbeing

How would you rate your current stress level? (0–10)

How well are you sleeping? (0–10)

Average hydration (glasses of water / day)

Caffeine / day

Exercise frequency

Alcohol / week

Anything else about your daily life — diet, work, caring responsibilities, recent changes — that may be relevant?

7. Hormonal Health (optional)

Current cycle phase / status

Last menstrual period (if applicable)

Hormonal symptoms you'd like supported (e.g. hot flushes, sleep, mood, cycle pain)

8. Other Care

GP / specialist / other practitioners currently involved in your care

I have spoken with my doctor about complementary care, where appropriate.

9. Consent & Acknowledgement

I understand that therapeutic reflexology, Bowen therapy, and Reiki are complementary to — not a replacement for — conventional medical care. I confirm the information above is true and complete to the best of my knowledge, and I will inform the practitioner of any changes. I consent to receive treatment and understand I may pause or stop a session at any time. I'd like to receive the quarterly newsletter (occasional, easy to unsubscribe).

Signed (type your full name) *

Date *

A few questions to help me prepare for our time together.