NEW CLIENT QUESTIONNAIRE Name * First Name Last Name Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Date of Birth * MM DD YYYY Age * Occupation * Siblings Marital Status Single Married Separated/Divorced Widowed In unsteady relationship Spouse/Partner Children Current Medical Doctor Othe Health Care Professionals Emergency Contact * How did you hear about Mind Body Soul Kinesiology? * How can I best support you? What would you like to focus on? * LIFESTYLE How many hours of sleep do you often get per night? * What is your exercise regime? * Smoking * Drug and Alcohol consumption * Supplements * Does your work environment involve harsh chemical? * Yes/No What is your typical diet? * Select one or more Meat and 3 veg High protein Vegetarian Vegan Dairy free Gluten free Refined sugar free Pescatarian Other Rough daily intake of Sugar, Tea, Coffee, Alcohol, Water, Soft drinks * Health History Select which of the following you have experienced in that last 6 months * Neck pain Back pain Headaches Tired/Fatigue Diabetes Dizzyness Ringing ears Numb/Tingling areas Nervous/Anxiousness Chest pain Depression Digestive Issues Asthma Restless sleep/Insomnia Regular flu's and colds High/Low blood pressure Heart condition Muscle aches and pains Joint pains Epilepsy None of the above Select which of the following you have experienced PRIOR to the last 6 months * Neck pain Back pain Headaches Tired/Fatigue Diabetes Dizzyness Ringing ears Numb/Tingling areas Nervous/Anxiousness Chest pain Depression Digestive Issues Asthma Restless sleep/Insomnia Regular flu's and colds High/Low blood pressure Heart condition Muscle aches and pains Joint pains Epilepsy None of the above Conditions/Illnesses not listed above Which of the above ticked boxes have been the most serve? What treatments/Healing modalities have you tried? * If any List any/all surgeries you've had and at what age List all major falls/accidents you've had over the past 10 years and any injuries incurred Are you pregnant * Family History Family patterns come in all shapes and sizes. Gaining an understanding of your family history can sometime help us to resolve the stress you are currently facing. Please list any relevant family history below. * I understand that Mind Body Soul Kinesiology offers treatment that is of a remedial therapeutic nature and not of a diagnostic/curative approach. I give my permission for my health history to be kept on file for the purpose of natural therapies treatment. I understand that all information within my file will be kept confidential at all times. I am attending of my own free will and consent and exercise my right to discuss and choose any suitable treatments available to me. * I Understand Thank you!
