The object of this questionnaire is to save time in the session and to give you more time to reply as fully as you can.

If you have any difficulty or concern answering any of the questions, please feel free to omit them. 

Strictly Confidential

 






First Name:

Surname:

Address (separated by commas)

Telephone:

Mobile:

Email:

Date:

Date of Birth:

Doctor's Name:

Practice Name:

Family Situation

If a child, parent's name:

Spouse/Partner's first name:

Children: Name & Age:

Weight: Height:

Are you happy with your weight? YN

If not, what is your ideal weight?

What other treatments are you having / have tried?

Medical History

Any past surgery, serious illness, accidents/injuries with approximate dates?

What was your health like as a child?

Was there anything abnormal about your birth?

What areas, problems or goals would you most like help with now?

List any emotional traumas/ episodes, with rough dates, as far back as you like. (e.g. bereavements, divorce, parents split-up etc.)

Any relationship problems?

Diet

Describe a typical day’s eating & drinking:

Breakfast

Lunch

Evening Meal

Between Meals

What do you do for exercise and relaxation?

Medication

Any current drugs and what for?

Any medication taken in the past, especially if for a long period?

Do you take any supplements? Which ones?

Tick if you are having or have had any of the following & add any comments such as for how long or when...

  I am having I have had
but not now
Comments
Poor Sleep Having Poor Sleep Have Had Poor Sleep
Lack of energy Having Lack of energy Have Had Lack of energy
Anxiety Having Anxiety Have Had Anxiety
Depression Having Depression Have Had Depression
Lack of confidence Having Have Had
Lack of motivation Having Lack of confidence Have Had Lack of confidence
Phobias Having Phobias Have Had Phobias
Fainting Having Fainting Have Had Fainting
Fits Having Fits Have Had Fits
Swollen Feet Having Swollen Feet Have Had Swollen Feet
Varicose Veins Having Varicose Veins Have Had Varicose Veins
Migraines Having Migraines Have Had Migraines
Vision Problems Having Vision Problems Have Had Vision Problems
Hearing Problems Having Hearing Problems Have Had Hearing Problems
Liver Related Problems Having Liver Related Problems Have Had Liver Related Problems
Heart Related Problems Having Heart Related Problems Have Had Heart Related Problems
Brain Related Problems Having Brain Related Problems Have Had Brain Related Problems
Chest Pains Having Chest Pains Have Had Chest Pains
Neck/Shoulder Pains Having Neck/Shoulder Pains Have Had Neck/Shoulder Pains
Back Pain Having Back Pain Have Had Back Pain
Joint Pain Having Joint Pain Have Had Joint Pain
Weak Bones Having Weak Bones Have Had Weak Bones
Bowel Problems Having Bowel Problems Have Had Bowel Problems
Parasite Problems Having Parasite Problems Have Had Parasite Problems
Blood Sugar Problems Having Blood Sugar Problems Have Had Blood Sugar Problems
Poor Circulation Having Poor Circulation Have Had Poor Circulation
Blood Pressure Problems Having Blood Pressure Problems Have Had Blood Pressure Problems
Lethargy Having Lethargy Have Had Lethargy
Genital Problems Having Genital Problems Have Had Genital Problems
Menstrual Problems Having Menstrual Problems Have Had Menstrual Problems
Menopausal Problems Having Menopausal Problems Have Had Menopausal Problems
Thyroid Problems Having Thyroid Problems Have Had Thyroid Problems
Sexual Problems Having Sexual Problems Have Had Sexual Problems
Muscle Cramps Having Muscle Cramps Have Had Muscle Cramps
Breathing Difficulty Having Breathing Difficulty Have Had Breathing Difficulty
Repeated Infections Having Repeated Infections Have Had Repeated Infections
Stuffy Sinuses Having Stuffy Sinuses Have Had Stuffy Sinuses
Repeated Cough Having Repeated Cough Have Had Repeated Cough
Runny Nose Having Runny Nose Have Had Runny Nose
Runny Eyes Having Runny Eyes Having Runny Eyes
Sensitive/Very Dry Skin Having Sensitive/Very Dry Skin Have Had Sensitive/Very Dry Skin
Dandruff/Sensitive Scalp Having Dandruff/Sensitive Scalp Have Had Dandruff/Sensitive Scalp
Verrucas/Feet Problems Having Verrucas/Feet Problems Have Had Verrucas/Feet Problems
Skin Rash Having Skin Rash Have Had Skin Rash
Spotty Skin Having Spotty Skin Have Had Spotty Skin
Food Cravings Having Food Cravings Have Had Food Cravings
Allergic Reactions
/Asthma/Hay Fever
Having Allergic Reactions/Asthma/Hay Fever Have Had Allergic Reactions/Asthma/Hay Fever
Other Problems Having Other Problems Have Had Other Problems

When you arrive for your session i'll ask you to sign a printed copy stating the following:

I understand that kinesiologists do not give medical diagnoses or treatment, and that it is my responsibility to consult my GP about any medical problem that I am aware of or become alerted to in the course of a kinesiology session.

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