New Client Form

CONFIDENTIAL QUESTIONNAIRE FOR NEW CLIENTS

Please answer all questions as honestly as possible and add any information you feel is relevant as this will assist me in treating you. If there is not enough space, please feel free to add any additional information at the end of the questionnaire.

Name *

First

Last *

Last

Phone | Mobile

Phone | Home

Email *

Date of Birth

Age

Sex

Height

Weight

What issues would you like me to address?

How long have you been experiencing these problems?

Do you know if there were any complications with your birth?

Yes

Did you grow up with both your parents?

Yes

Do you have any siblings?

Yes

Did you feel loved?

Yes

Did you have a happy childhood?

Yes

Did you feel secure/safe?

Yes

Any additional information

Do you have a happy home environment?

Yes

Are you in a relationship?

Yes

Do you have children?

Yes

Do they live with you?

Yes

Do you work?

Yes

If yes, what is your occupation?

Do you enjoy your work?

Yes

Other

What exercise do you do and how often?

Do you smoke?

Yes

Indicate how much liquids you drink each day:

# cups of coffee/ tea

Indicate how much liquids you drink each day:

# glasses of water

Indicate how much liquids you drink each day:

# units of alcohol

Indicate how much liquids you drink each day:

# glasses of fizzy drinks

How many hours sleep do you get per night?

Do you wake feeling refreshed?

Yes

Other

Do you feel that you are lacking energy?

Yes

Other

Do you consider yourself stressed?

Yes

Other

What causes your stress?

Do you find it hard to relax?

Yes

How often do you relax?

Are you happy with your weight?

Yes

Do you struggle to lose weight?

Yes

Women Only

I understand that the next 8 questions are only applicable for women

Do you have a menstrual cycle?

Yes

Are you on the pill or other forms of contraception?

Yes

Do you have any breast pain?

Yes

Have you had any pregnancies?

Yes

How many babies have you given birth to?

Any complications during pregnancy or childbirth?

Are you in menopause?

Yes

Are you on HRT or any other medication for menopause?

Yes

Are you under the care of a practitioner at the moment?

Yes

If yes, please specify.

Are you on any medication?

Yes

Are you taking any supplements?

Yes

Are there any events in your life, either emotional or physical which you would like me to know about?

Yes

If yes, please specify.

Disclaimer

I appreciate that kinesiologists do not give medical diagnosis or treatment. I understand that my GP is responsible for my own medical care and/or my dependents.

I agree to my records being held in line with GDPR regulations and give explicit consent for my data to be held in accordance with these regulations.

I accept responsibility for my own health and wellbeing and for participation in the methods, treatment & suggestions made during kinesiology sessions.

I understand that fees are due at the end of each session and that nutritional supplements are charged separately.

If you are human, leave this field blank.

New Client Questionnaire

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