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
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
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?
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
Chronic tiredness Depression
Thrush/candida Chest pains
Liver/gall bladder problems. Osteoporosis
Kidney problems Asthma
Hay fever/sinusitis Catarrh
If you have any other symptoms or concerns please list these below
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)
Painful Losses (family, friends, pets, jobs, relationships, homes, etc).
Any significant habits?
Do you drink coffee or tea? How many daily?
and approximate times you eat.
Do you take any nutritional supplements?
How much water do you drink daily?