Kinesiology — MAW Kinetics

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

DOB

Phone

(###)

###

####

Occupation

Health

Very Good

Good

Fair

How did you hear about us

Referred? By who?

Preffered contact

Phone/Text

Other Conditions?

Medical History/Illnesses/Injuries:

Exercise/Hobbies/Interests:

How do you manage stress?

Allergies

Goals/Health Concerns

List the reasons/goals for your visit in order of importance? Rate impact on life on a scale of 1-10

How will you feel once you have reached your goal?

Nutritional Information - PTO

Do you take any nutritional supplements, vitamins, minerals, herbs, etc?

Please list any food aversions and/or foods you dislike.

Do you crave any food frequently?

Yes

If yes, what kind of foods?

Client/Guardian Consent for Kinesiology Health Care:

To the best of my knowledge I have disclosed all information regarding my past and present state of health to enhance the Kinesiologist’s ability to assist positive results. I agree to alert my practitioner of any physical/ emotional changes as they occur. I also understand that 24hour notice must be given if an appointment needs to be rescheduled, and that a missed appointment may incur charges that I must pay. I acknowledge that the Kinesiologist adheres to best practice policies and that all information provided or exchanged during consultations follows the current Privacy Act as required by Law.

Name: Parent/Guardian:

Date

YYYY

Client Information Sheet

STAY UPDATED

CONTACT

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