Client Information Form

Your name

Your date of birth

Your address

Your email

Your phone

Your occupation

Please indicate if you have taken the COV19 injection:
YesNo

When was your COVID vaccination:

Please provide current symptoms or issues you are experiencing

Are you currently under the care of a doctor or hospital for any condition(s)?
YesNo

If so, please give brief details

Name of family Doctor

Have you been clinically diagnosed with any medical conditions in the past?
YesNo

If yes, what medications are you currently taking?

Are you pregnant or trying to become pregnant?
YesNo

Have you undergone recent surgery?
YesNo

Do you suffer or experience any of the following symptoms?
FatigueHeartburn/indigestionConstipationHeadachesDizzinessSugar cravingsMood swingsDepressionDry skinSleep issuesPainDiarrhoeaHay feverBloating/flatulenceEczemaNauseaNumbnessOther

Dietary details

How would you describe your appetite?
PoorAverageGood

Do you eat three meals a daily?
YesNo

What nutritional supplements do you take on a regularly basis?

TERMS & CONDITIONS

I appreciate that Kinesiologist Practitioners do not give medical diagnosis or treatment.
I am fully responsible for the option of ordering and taking my chosen supplementation.
I understand that my G.P is medically responsible for the care of my dependents and myself and that it is fully my responsibility to inform my doctor of any supplement or lifestyle changes I am making.

CANCELLATION POLICY

My time is valuable. Please let me know if you cannot keep an agreed appointment so I can firstly re-schedule with you and secondly offer your therapy session to someone else in need.

A cancellation fee of $30 will be required if you cancel your appointment without sufficient notice for me to fill your spot. (less than 24 hours of your booked appointment time)

I agree to these terms and conditions and cancellation policy