New Client Form – Adult

ADULT INTAKE FORM – EMMA FISHER KINESIOLOGIST PRIVACY POLICY: All information collected is confidential and complies with the Commonwealth Government Privacy Act (1988) and the Health Record Acts (2001)

Please print and complete, then bring with you into clinic. Alternatively email it through to emma@ekinesi.com.

Name:
Date of Birth:
Address:
Email:
Phone:
How did you come across Emma Fisher Kinesiologist?

Do you have siblings?
Do you have a partner?
Do you have children? If so, what age(s).

Your current occupation/role/industry/any areas of study?
Please list any past injury, surgery or trauma (include date, age if possible):

Additional past illnesses or conditions (include date, age if possible):

Current medication:
Current supplements/vitamins:
Details of your birth if known (Natural, C-section, traumatic etc):

Food preferences: (For example, meat/vegetarian/fish-only/vegan, no dairy/no gluten)

Do you have any allergies/sensitivities or aversions?

Daily intake:   Coffee    Tea     Water    Alcohol

Is frequency of bowel movement or passing urine regular?

Hours of sleep per night:

Do you have trouble sleeping?

Exercise routine:

Energy levels: High/Low/Variable
Emotional landscape: Highly emotional/Not very emotional/Variable

Do you find it challenging to regulate your emotions?

Do you suffer from any physical pain or illness?

Please list any reasons for coming into clinic and any additional information that may be relevant (we will talk through the information anyhow so don’t be concerned if you miss something!):

I understand that kinesiology only balances energy and it does not treat disease: Yes/No

I understand that kinesiology should not be construed as a substitute for medical examination,diagnosis, or treatment of any medical condition, and that I should see a physician, or other qualified medical specialist for any physical or mental ailment I am aware of: Yes/No

I would like to receive SMS reminders before my sessions: Yes/No

I am happy to receive email correspondence: Yes/No

Signed:

Name printed:

Date: