Client Intake Form

Please provide us the information below before your first session

    Something About You

    Name*

    Date of Birth*

    Weight

    Identifying Gender*

    Phone Number*

    Email Address*

    Address

    Emergency Contact*

    How did you hear about us?

    Have you had kinesiology before?* YesNoDon't Remember

    What other forms of therapy have you used/are using?

    Please provide details


    Family and Work

    Relationship Status SingleMarriedDefacto

    Partner Details

    How would you describe your relationship with your partner?

    Do you have Kids? YesNo

    Kids Details

    Do you have Siblings? YesNo

    Siblings Details

    Describe your relationship with your parents/siblings

    Are your Parents... TogetherSeparatedRe-PartneredPassed Away

    What best describes your current situation?
    StudyWork Full-timeWork Part-timeSole TraderBusiness OwnerStay at Home CarerRetiredOther

    Occupation Details

    Do you enjoy your work? YesNo

    Is your work stressful? YesNo

    Share more details about your work life, stress etc.


    Lifestyle

    What is your current Energy Level?

    What is your current Stress Level?

    Current Living Situation ExcellentGoodAveragePoor

    Please share more details about your living situation

    How many hours do you sleep each night?

    Sleep At

    Wakeup At

    Do you have trouble falling asleep? YesNo

    If Yes, how long does it take?

    Do you wakeup during the night? YesNo

    How Many Times?

    What Time?

    Describe how you feel when you wakeup each morning.

    Do you Exercise? YesNo

    How many times per week?

    What exercise do you do and for how long?

    Do you Meditate? YesNo

    How many times per week?

    Daily intake of sugar, coffee, tea, alcohol and water

    What are your hobbies / interest / passion

    Do you have supportive friends?

    Do you like your bedroom? YesNo

    Please explain what you like/dislike about your bedroom


    Nutrition and Diet

    Please choose what best describes your normal everyday intake.

    What is your daily water consumption?

    Food Intolerances

    Additional Details

    Briefly describe your normal daily food intake


    Habits, Drugs and Supplements

    Do you drink alcohol? YesNo

    How many times per week?

    Do you smoke? YesNo

    For how long?

    How many?

    Do you take any of the following?

    Please provide details

    Have you had any previous surgeries? Please share details


    For Female Patients Only

    Are you Pregnant? YesNo

    If Yes, what is your Due date?

    Do you suffer from menstrual problems? YesNo

    Cycle Duration?

    Describe your cycle HeavyPainfulRegularIrregularMenopausalOther

    Are you currently using contraception? YesNo

    In What Form?

    Are you trying to conceive? YesNo

    For how long?

    What is the priority issue that you would like me to work on in your session with me ?

    Declaration

    I declare that all the information above is true and correct and I indemnify Health & Beyond of any liability for any false or misleading statements given.

    It is understood and accepted that this session provided by Health & Beyond is of a remedial therapeutic nature and not of a diagnostic/curative approach.

    It is also understood that the results of this session are not guaranteed in any way.

    The information gathered here, as well as notes and information taken in every session is kept private and secure.

    It will remain the property of Health & Beyond as client history records.

    Personal information may be used for any future communication as deemed appropriate.

    I understand that payment is made at time of service by either cash, Visa or Mastercard.

    I agree to give 24hours notice for cancellation for any appointment or a fee of 50% of the consultation fee will be charged.

    I hereby give Ritika Kapoor permission to conduct Kinesiology on me.