Kinesiology Consultation Form

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Kinesiology Consultation Form

Personal Details

Please fill in this form if this is your first time appointment

* Indicates required field

Name *

First

Last

Email *

Date of Birth (DD/MM/YYYY) *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Comment *

Personal Data Record

Recommend to by : *

Reason(s) for Visit *

Are you presently under medical supervision by a doctor or hospital ? *

Yes No

Are you currently taking any medication *

Yes No

If yes, please give brief details *

If yes, please give details *

Health & Lifestyle Questions

List typical snacks *

Smoking *

Never Smoked Used to Smoke Currently Smoke

Alcohol Intake *

Red Wine White Wine Beer Spirits Don't Drink

Units Per Day *

Units Per Week *

Water Intake *

When do you drink water? *

Away from meals With meals

Energy Levels *

Do Your Energy Levels Fluctuate *

Sleep Quality *

You wake up in the early hours You wake up rested You sleep between 7-9 hours You have consistant bed time & wake up time

Frequency of Bowel Movements *

Stool Consistency *

Hard Soft Alternate between both

Menstration (Ladies) *

Regular Painful

Frequency of Unrination *

Do you have to get up a night *

Often Some times Never

Do you suffer from stress incontinence *

Yes No

What are your main stressors (things in life that cause you stress at the moment) *

How are your relationships (family, friends, work) *

How are you feeling emotionally *

Please list Accidents & Injuries *

Declaration

I take full responsibility for my own health and well being,
and accept the outcome of any consultation or treatment I receive from Julia Griffiths;
I accept comments or advice given during the consultation as being
complementary and not an alternative to qualified professional medical treatments.
I will consult my GP regarding any supplements if I am taking medication

Full Name Signature (Please type your full name as a signature) *

I agree to the above declaration *

I agree I disagree

Submit

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