CHILDS 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. It would be helpful for our work together if you could record along with the list of concerns a rating of 0 - 10 of how severe the 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

Phone Blood group
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.

How did you hear about HK ?

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, mothers health, method of delivery etc.)

Were you breast fed?

Do you have any brothers or sisters? Please give ages.

Have you had normal childhood vaccinations?


Have you had 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.


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

Have you had any dental treatment

Who else have you consulted about your current concerns?

Any significant habits:

Any phobias:

Any concerns about school or home life?

Describe a typical days eating and drinking

Breakfast

Lunch

Tea

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

Do you take any nutritional supplements?

How much water do you drink daily?

If you are suffering from any of the following please scale the intensity of the problem from 0-10,
(0 being no symptoms and 10 being unbearable)

Poor sleep_________________________Regular colds/respiratory infections___
Vertigo___________________________Constipation_____________________
Hearing problems/Tinnitis_____________Loose bowels___________________
Dyslexia__________________________Indigestion______________________
Epilepsy__________________________IBS____________________________
Nervous twitching__________________High blood pressure________________
Headaches________________________Low blood pressure________________
Migraines_________________________Poor circulation__________________

problems__________________________Anaemia________________________
Anxiety attacks_____________________Chronic tiredness_________________
Depression________________________Thrush/candida___________________
Chest pains_______________________Neck/shoulder/arm pains____________

Urinary problems___________________Lower back pain/sciatica____________

Liver/gall bladderproblems__________Osteoporosis_______________________

Kidney problems__________________Arthritis_________________________

Asthma________________________Leg/knee pains_____________________

Hay fever/sinusitis_______________Painful feet________________________

Catarrh________________________Other pain, please specify______________

Eczema or psoriasis________________Diabetes

Food cravings (Please specify)________________________________________

If you have any other symptoms please list these below and any further information that you feel may be relevant

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 required.

Signed:____________________________________Date:_________________________