Kinesiology-Intake Form

Name:*

First NameLast Name

Email:*

example@example.com

Address:*

Street Address

Street Address Line 2

CityState / Province

Poscode

Phone Number:*

Area CodePhone Number

MaleFemaleOther

Marital /Relationship Status

Date of Birth*

Age

Occupation:

How long in this work

Family GP

Other Health Professional

Siblings

(Name, Age, Gender)

Your place in family

Spouse

(Name, Age, Gender)

Children

(Name, Age, Gender)

Cultural Background

Religion (are you currently practicing?)

Past Trauma

(incl. date, age)

Past Surgery

(incl. date, age)

Female - Period Cycle

in days

PMS / Menopause Symptoms

lists down all the symptoms

Current Medication

Current Supplements

Daily Intake-Coffee

cups / in ml

Daily Intake-Tea

cups / in ml

Daily Intake-Alcohol

cups / in ml

Daily Intake-Water

cups / in ml

Frequency-Bowel Movement

in day

Frequency-Passing Urine

how many times?

Hours of Sleep

per night

Exercise

in a week

Neck & Shoulder

describe the pain

Back

describe the pain

Knee & Feet

describe the pain

Elbow & Hands

describe the pain

Any other pain

describe the pain

HighMediumLowVariable

Emotional/Mental State

Finances State

Relationship with partner

Parents

Siblings

Work

Self Esteem

Reasons why you are here

incl. history of current problem

Is there anything else the practitioner need to know?

1. I have stated all conditions that i am aware of and this information is true and accurate.

2. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there should be no liability on the practitioner's part should i forget to do so.

3. I understand that Kinesiology only balances energy and it does not treat disease.

4. I understand that Kinesiology should not be construed as a substitute for medical examination, diagnosis or treatment of any medical condition, and that I should see a physician, or other qualified medical specialist for any physical or mental ailment I am aware of.

5. I understand there is a cancellation policy. I may cancel or change my appoinment time up to 48 hours in advance of my session. If I do not show up for my appoinment, I will be charge 50% a penalty fee.

Signature

Date