Personal History Form

Personal History Form

Client assessment form for before the first Health Kinesiology session
  • Strictly Confidential

  • The object of this questionnaire is to save time in the session and to give you more time to reply as fully as you can. If you have any difficulty or concern answering any of the questions, please feel free to omit them.
  • Family Situation

  • Medical History

  • Diet

    Describe a typical day’s eating & drinking:
  • Medication

  • Tick if you are having or have had any of the following or write any comments such as for how long or when...

  • Declaration

    When you arrive for your session i'll ask you to sign a printed copy stating the following:

    I am solely responsible for my health. It is my responsibility to research every single supplement, herb and technique before utilising it. I am fully responsible for how I choose to use the information given to me by Oksana Roberts.

    By signing you are confirming below to confirm you are happy with this and consent to submit your information to Oksana solely for the purpose of a Health Kinesiology session.