Personal History Form Personal History Form Client assessment form for before the first Health Kinesiology session Strictly ConfidentialThe 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.Full NameAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code TelephoneEmail Date of BirthFamily SituationPlease select one of the followingSingleLiving AloneLiving with ParentsLiving with PartnerMarriedSeparatedOtherIf a child, what is the parent's name?Spouse/Partner's first name?Children? Name and age?WeightHeightWhat other treatments are you having / have tried?Medical HistoryAny past surgery, serious illness, accidents/injuries with approximate dates?Was there anything abnormal about your birth?What areas, problems or goals would you most like help with now?List any emotional traumas/ episodes, with rough dates, as far back as you like. (e.g. bereavements, divorce, parents split-up etc.)Any relationship problems?DietDescribe a typical day’s eating & drinking:BreakfastBetween MealsLunchEvening MealWhat do you do for exercise and relaxation?MedicationAny current medication and what for?Any medication taken in the past, especially if for a long period?Do you take any supplements? Which ones?Tick if you are having or have had any of the following or write any comments such as for how long or when...Poor SleepI am havingI used to have but not nowLack of energyI am havingI used to have but not nowAnxietyI am havingI used to have but not nowDepressionI am havingI used to have but not nowLack of confidenceI am havingI used to have but not nowLack of motivationI am havingI used to have but not nowPhobiasI am havingI used to have but not nowFaintingI am havingI used to have but not nowFitsI am havingI have had but not nowSwollen FeetI am havingI used to have but not nowVaricose VeinsI am havingI used to have but not nowMigrainesI am havingI used to have but not nowVision ProblemsI am havingI used to have but not nowHearing ProblemsI am havingI used to have but not nowLiver Related ProblemsI am havingI used to have but not nowHeart Related ProblemsI am havingI used to have but not nowBrain Related ProblemsI am havingI used to have but not nowChest PainsI am havingI used to have but not nowNeck/Shoulder PainsI am havingI used to have but not nowBack PainI am havingI used to have but not nowJoint PainI am havingI used to have but not nowWeak BonesI am havingI used to have but not nowBowel ProblemsI am havingI used to have but not nowParasite ProblemsI am havingI used to have but not nowBlood Sugar ProblemsI am havingI used to have but not nowPoor CirculationI am havingI used to have but not nowBlood Pressure ProblemsI am havingI used to have but not nowLethargyI am havingI used to have but not nowGenital ProblemsI am havingI used to have but not nowMenstrual ProblemsI am havingI used to have but not nowMenopausal ProblemsI am havingI used to have but not nowThyroid ProblemsI am havingI used to have but not nowSexual ProblemsI am havingI used to have but not nowMuscle CrampsI am havingI used to have but not nowBreathing DifficultyI am havingI used to have but not nowRepeated InfectionsI am havingI used to have but not nowStuffy SinusesI am havingI used to have but not nowRepeated CoughI am havingI used to have but not nowRunny NoseI am havingI used to have but not nowRunny EyesI am havingI used to have but not nowSensitive/Very Dry SkinI am havingI used to have but not nowDandruff/Sensitive ScalpI am havingI used to have but not nowVerrucas/Feet ProblemsI am havingI used to have but not nowSkin RashI am havingI used to have but not nowSpotty SkinI am havingI used to have but not nowFood CravingsI am havingI used to have but not nowAllergic Reactions /Asthma/Hay FeverI am havingI used to have but not nowOther ProblemsI am havingI used to have but not now 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.CAPTCHA
