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General Assessment
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Date:
Please take a little time to answer the following questions to help me work out how best to help you.
Name:
Address:
Telephone Number:
Email address:
Date of Birth:
Occupation:
Number of hours brisk exercise taken per week:
How many cups or glasses of the following do you drink :
Per Day?
Per Week?
Squash?
Tea?
Coffee?
Water?
Fizzy drinks?
Alcohol?
Herbal tea?
What food would you hate to go without?
What food do you dislike?
Are you taking any supplements?
Yes
No
If so, which?
Are you on any medications at the moment?
Yes
No
If so, which?
Are you currently seeing another practitioner?
Yes
No
If so, what are your reasons?
What are you hoping to gain from your balancing sessions?
Would you say you were currently:
Very stressed?
Mildly stressed?
Relaxed?
Please tick the level of difficulty you have with the following:
very difficult
quite difficult
slightly difficult
no problem
Reading
Writing
Co-ordination
Hearing
How did you hear about kinesiology?
I accept full responsibility for my own health and well-being and accept the outcomes of any advice or treatment I receive with this practitioner. I accept them as being complementary to and not an alternative to qualified professional medical treatment.
Name:
Date:
