Confidential Client Information Form

Client Intake Form

Please complete this intake form carefully.
Full Name

First NameLast Name
What is your age?
What is your gender?
Email Address
example@example.com
Emergency Contact

First NameLast Name
Emergency Contact Number
Format: (000) 000-0000.
Which of following best describes your current situation:

StudyingWork Full timeWork Part TimeCasual WorkerBusiness OwnerAt home CarerRetiredOther
Occupation. & Duration .
Do you enjoy your work?

YesNoNot sureWant to change
Is your work stressful?

YesNoSometimes
Average hrs of sleep per night?
Do you fall asleep easily?

YesNo
Do you wake during the night?

YesNoSometimesOther
Are you currently seeing any health professionals? If so ,who
Are you on any medication ?
Females: Do you still menstruate,if so are you regular?
Females: Are you pregnant,and if so how many weeks?
Please list any vitamins you take .
What are your interests / hobbies?
Please list : exercise /movement
Self care practices / meditation
Average daily diet :
Daily water intake:
Do you drink coffee/tea : if so how many per day?
Do you smoke: Yes / No
Do you drink alcohol if so how often:
Do you take recreational drugs : if so what and how often?
What is the main reason for visiting me ?
What would you like us to achieve together in this session?
What would you like us to achieve together in this session?
If i could give you 3 wishes ,what would they be:
I declare that the above information is true and correct. I understand that the session provided by Dianne Kerr Kinesiologist is of a remedial therapeutic nature. I understand that the session is here to assist me in better understanding myself and to assist me on my healing journey.

Date:
Signature
Should be Empty:

Client Intake Form