Client Information Form

Welcome to Abundant Health Kinesiology

Prior to your 1st session you will need to complete your Client Kinesiology Form by clicking on the next button below, adding all the details and pressing submit.

Once this form is submitted you will return to the website and I recommend you go the services page and under the Session Information section read about "What to know before your session".

If you have any problems with submitting this form please text me at 0433 067 133.

Client Information Form
Subject
Full Name

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState

Post Code
Email:
Date of Birth

MonthDayYear
Mobile
Please enter a valid phone number.
Occupation
Relationship Status
No. Of Children
Are you pregnant
Please briefly describe what you would like to achieve from your kinesiology appointment ? I would like to have kinesiology to help me with .........
Are you currently receiving any other therapies or medical treatment? If yes, what?
How did you hear about Abundant Health Kinesiology
PHYSICAL PROFILE
Major surgery/Accidents and When did these happen:
Any Physical Pain ? and where?
If yes to physical pain, what is your pain stress rating: 0=No Pain 10=Extreme Pain
How did you get this pain?
What activities do you do that make you notice the pain the most? Standing from sitting, driving the car, dressing etc.
Please list the physical activities that you participate in outside of the gym and outside of work.:
Your usual blood pressure is
Are you concerned with any Immune OR Hormonal issues? Please explain:
NUTRITIONAL PROFILE
Please list any Vitamins/Minerals/Medications or Recreational Drugs that you take and what you take them for:
Please list any allergies:
How would you describe your energy levels:
Water intake per day:
Exercise
Sleep Patterns
Are you a smoker:
To the best of my knowledge I have disclosed all information regarding my past and present state of health to enhance the Kinesiologist's ability to assist in achieving positive results.

I understand that Kinesiology is a complementary therapy and is not a replacement for medical care when necessary and that results are not guaranteed.

I acknowledge that the Kinesiologist adheres to best practise policies and that all information provided or exchanged during consultations follows the current Privacy Act as required by Law.

If you are unable to keep your appointment date please reschedule or cancel it either using the online system, calling or texting anytime to 0433 067 133. A cancellation fee may apply for less than 24hrs notice. I appreciate you letting me know asap so the time slot can be made available for someone else that may need support.
I AGREE TO THE ABOVE TERMS & CONDITIONS!*

Yes
Should be Empty:

Client Information Form

PHYSICAL PROFILE

NUTRITIONAL PROFILE