Client Information Form

This information provided by you will be treated as strictly confidential and will not be shared with any other party.

    Your name

    Your date of birth

    Your address

    Your email

    Your phone

    Your occupation

    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

    Alcohol (per glass) DailyWeekly None123456-10More than 10
    Cigarettes DailyWeekly None123456-10More than 10
    Fizzy drinks DailyWeekly None123456-10More than 10
    Cups of tea DailyWeekly None123456-10More than 10
    Cups of coffee DailyWeekly None123456-10More than 10
    Fruit juice DailyWeekly None123456-10More than 10
    Water (litres) DailyWeekly None123456-10More than 10
    Confectionary/gum DailyWeekly None123456-10More than 10
    Dairy products DailyWeekly None123456-10More than 10
    Bread (slices, white or brown) DailyWeekly None123456-10More than 10
    Red meat DailyWeekly None123456-10More than 10
    White meat DailyWeekly None123456-10More than 10
    Sugar (teaspoons) DailyWeekly None123456-10More than 10
    Fruit DailyWeekly None123456-10More than 10
    Cooked/raw vegetables DailyWeekly None123456-10More than 10
    Eggs DailyWeekly None123456-10More than 10
    Fish DailyWeekly None123456-10More than 10
    Cereal DailyWeekly None123456-10More than 10

    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)