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Kinesiology Consultation Form
Personal Details
Please fill in this form if this is your first time appointment
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Indicates required field
Name
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First
Last
Email
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Date of Birth (DD/MM/YYYY)
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Phone Number
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Comment
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Personal Data Record
Recommend to by :
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Reason(s) for Visit
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Are you presently under medical supervision by a doctor or hospital ?
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Yes
No
Are you currently taking any medication
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Yes
No
If yes, please give brief details
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If yes, please give details
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Health & Lifestyle Questions
List typical snacks
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Smoking
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Never Smoked
Used to Smoke
Currently Smoke
Alcohol Intake
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Red Wine
White Wine
Beer
Spirits
Don't Drink
Units Per Day
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None or don't drink daily
0 - 1 Units
1 - 2 Units
2 - 3 Units
3- 4 Units
More than 4 Units
Units Per Week
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None or Rarely
0 - 5 Units
5 - 10 Units
10 - 15 Units
15 - 20 Units
20 - 25 Units
25 - 30 Units
Water Intake
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Less than a litre
Less than 2 litres
More than 2 litres
When do you drink water?
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Away from meals
With meals
Energy Levels
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1 (low)
2
3
4
5 (high)
Do Your Energy Levels Fluctuate
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Yes
No
Sleep Quality
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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
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You can miss days
Once a day
Twice a day
More than twice a day
Stool Consistency
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Hard
Soft
Alternate between both
Menstration (Ladies)
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Regular
Painful
Frequency of Unrination
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Once a day
Twice a day
Three times a day
More frequently
Do you have to get up a night
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Often
Some times
Never
Do you suffer from stress incontinence
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Yes
No
What are your main stressors (things in life that cause you stress at the moment)
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How are your relationships (family, friends, work)
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Great
Ok
Challenging
Don't go there
How are you feeling emotionally
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Happy
Sad
Drained
Please list Accidents & Injuries
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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)
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I agree to the above declaration
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I agree
I disagree
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