In order to assist us with the consultation process, all clients are required to complete the below confidential form.
If you have any questions while completing this form, please contact Colleen.

Health Evaluation Form

Patient details

Medical details

0 = minimal stress 10 = extreme stress

Please answer WEEKLY servings of the following:

Other medical information

WHAT WOULD YOU LIKE TO SEE FROM YOIUR KINESIOLOGY TREATMENT?

IMPORTANT NOTE. PLEASE READ AND SIGN THE FOLLOWING:

I appreciate Kinesiology Practitioners do not give medical diagnosis or treatment.
I understand that my G.P is medically responsible for the care of my dependents and myself.
Let me know if you cannot keep an agreed appointment so I can firstly re-schedule with you and secondly
offer your therapy session to someone else. On this basis I will need at least 24 hours notice (unless
exceptional circumstances), otherwise a minimum charge (75%) will be incurred.

Sending