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.
Child Name:
Child Date of Birth:
Address:
Parent/Guardian’s name:
Parent/Guardian’s email:
Parent/Guardian’s phone:
How did you come across Emma Fisher Kinesiologist?
Does the child have siblings? If so, age(s)?
Is the child at childcare/kinder/school/homeschool?
Please list any past injury, surgery or trauma (include date, age if possible):
Past illnesses or conditions (include date, age if possible):
Current medication:
Current supplements/vitamins:
Details of their birth (Natural, C-section, fast/slow/traumatic etc):
Food preferences: (For example, meat/vegetarian/fish-only/vegan, no dairy/no gluten)
Does the child have any allergies/sensitivities or aversions?
Daily intake: Caffeine_____ Sugar drinks____Water____
Is frequency of bowel movement or passing urine Regular or Excess/Deficient?
Does the child have trouble sleeping?
Hours of sleep per night:
Exercise routine/classes/teams/interests:
Energy levels: __High __Medium __Low
Emotional landscape: __Highly emotional __Fairly even___Low mood
Does the child find it challenging to regulate emotions?
Does the child suffer from any physical pain or illness?
Does the child experience: (please bold, or tick if relevant)
- ● Difficulty concentrating or following instructions
- ● Impulsive behaviours (not in line with development stage/age)
- ● Highly independent or finds things difficult to do alone
- ● Fear of new situations
- ● Learning challenges (highlighted as an area of concern my a teacher)
- ● Inability to cope with new situations/has to have things their way
- ● Either regular fatigue, colds, viruses, itchy skin, headaches
- ● Accident prone/clumsiness/co-ordinate challenges
- ● Late in any development goals/ stages (from 0-7 years)
- ● Physical development within normative ranges
- ● Socially comfortable
- ● Slow auditory or visual processing of information
Any additional information?
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!):
Please email through separately any extra information you wish to keep confidential and undisclosed in front of the child.
Please note that for children aged 12 and over I prefer to seek their permission before sharing details of their sessions where Parent/Guardian is not present.
I understand that kinesiology only balances energy and it does not treat disease: Y/N
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: Y/N
I would like to receive SMS reminders before my sessions: Y/N
I am happy to receive email correspondence: Y/N
Signed:
Parent/Guardian Name printed:
Date: