ADULT CONSULTATION FORM
Please fill in the consultation form below in as much detail as possible, some questions may not seem relevant to your particular concerns, but they all help to give me a clearer picture of your state of health and how any illnesses or concerns have built up. It would be helpful for our work together if you could record along with your list of concerns a rating of 0 - 10 of how severe your symptoms or concerns are at present ( 0 being no problem and 10 being unbearable) This gives a clear guideline that enables us to clearly monitor your improvements. Thanks, Catherine.

Name Date of Birth
Address

Blood Group
Email
Phone
GP’s name, address & phone number.

Are you receiving any medical treatment at present?

Please list any prescription medications, herbs, supplements or homeopathic remedies that you are.. taking at present, and please bring these with you to your first appointment.


How did you hear about Health Kinesiology ?
How long have you lived in your current home? How long did you lived in your previous home?

Please describe the concerns you would like to address in your Kinesiology session..

PERSONAL HEALTH/MEDICAL HISTORY
Was there anything abnormal about your birth(ie. premature, method of delivery etc.)
Were you breast fed?

Did you have normal childhood vaccinations? Please list if possible and list any received since


list any childhood illnesses.


list and surgical operations, serious illnesses/injuries/accidents with approximate dates

Please list any medication taken over a long period of time with dates if possible.


Known allergies/intolerances (please indicate if severe), include foods, dust, moulds, pollens, animals, chemical sensitivities, drugs etc.



Dental history (braces, extraction's, filling materials, amalgams replaced, fluoride treatment)..


Who else have you consulted about your current concerns?


YOUR GENERAL HEALTH AT THE PRESENT TIME -
ENERGY, concentration, short term memory and energy levels? How would you rate these? Have they deteriorated?



SLEEP any problems getting to sleep or waking in the night, do you feel tired or refreshed when you wake?



MOTIVATION AND CREATIVITY - do you enjoy hobbies or other interests, are you able to motivate yourself to achieve your goals?



MUSCLES AND JOINTS - aches and pains-where? muscular tension, arthritis, sciatica, better or worse for cold/ heat/ damp /movement?



HEADACHES - frequency, intensity, any specific area. migraines.



HAIR, SKIN, NAILS - any problems ie dandruff, thinning hair, oily skin, eczema, psoriasis, weak or thickened nails.


URINATION, frequency, any difficulty, infections, prostate problems.

DIGESTION, Wind, discomfort, indigestion, bloating, acid reflux, irritable bowel syndrome, diarrhoea, constipation, frequency going to toilet, are you aware of any food sensitivities,

MENSTRUATION Periods: heavy, painful, no’ of days bleeding, PMT, HRT, contraceptive pill, menopause/ pregnancy/children etc.

IMMUNE SYSTEM - do you get frequent coughs/colds and how do you treat these?


Do you suffer with any of the following? Please rate from 0-10 (0=no problem, 10= unbearable)..
Hearing problems/Tinnitus Dyslexia
Epilepsy High or low blood pressure

Poor circulation Sight problems/glasses/lenses

Anaemia Anxiety attacks
Chronic tiredness Depression
Thrush/candida Chest pains
Liver/gall bladder problems. Osteoporosis
Kidney problems Asthma
Hay fever/sinusitis Catarrh
Diabetes

If you have any other symptoms/concerns please list these below

LIFESTYLE/EMOTIONAL HISTORY
Occupation Do you find your job fulfilling and stimulating?


Family, do you have a partner? Children or any other dependants? Names of family members.


Are there any especially troublesome relationships in your life? (Family, friends, colleagues etc)
Past:

Present:


Painful Losses (family, friends, pets, jobs, relationships, homes, etc)..

How do you feel about your life / job / social life / home life?


Any significant habits:

Any phobias:

Do you smoke ? drink alcohol or take any recreational drugs? Please state approximate amounts and frequency


Do you drink coffee or tea? How many daily?

Describe a typical days eating and drinking, including all food, drinks, supplements and medication.
and times you eat.
Breakfast


Lunch


Evening meal

What kind of things do you eat/drink between meals?

Any food cravings, Please specify types of foods and any particular times that cravings are worst.


Do you take any nutritional supplements?


How much water do you drink daily?

Do you exercise?

How do you relax?

Height Weight (approximately) Weight 5 years ago (approximately)

I appreciate that Kinesiologists do not give medical diagnosis and treatment, but work to improve energy flow throughout the body, and that for maximum benefit a course of treatments may be needed.

Signed:____________________________________Date:_________________________