consultation Form

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.

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/Reflexology ?
How long have you lived in your current home?

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

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

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

Please list any childhood illnesses.
Please list any 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, extractions, 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?

HEADACHES – frequency, intensity, any specific area. Migraines?

HAIR, SKIN, NAILS – any problems .i.e. 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, number of days bleeding, PMT, HRT, contraceptive pill, menopause/ pregnancy/ number and ages of children if any.
IMMUNE SYSTEM – do you get frequent infections and how do you treat these? When did you last receive antibiotics?

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 or concerns please list these below

LIFESTYLE/EMOTIONAL HISTORY
What is your occupation and 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 approximate times you eat.
Breakfast

Lunch

Evening meal

What kind of things do you eat or 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 understand that Kinesiologists do not give medical diagnosis and treatment, but work to detect and correct energy imbalances throughout the body’s energy systems and that for maximum benefit a course of treatments may be needed.
Signed:____________________________________Date:_______________________
Privacy Policy 
Consultation Forms
Personal and health information is collected prior to treatment to rule out any contraindications to treatment and to enable the most appropriate and beneficial treatment to be ascertained, this is also useful at further appointments to evaluate improvements and any need to change the course of treatment.
No personal information is stored digitally. Once I have received consultation forms by email I print them off and delete the original email file.
Information is never disclosed to third parties.
Information is kept securely in a filing cabinet and is destroyed three years after the end of the treatment period (this is a registration adn legal requirement)).
Contact information
Personal contact information (name, email, phone, address) is kept for the purpose of scheduling appointments and if necessary to provide additional therapeutic information following treatments.