Harmony Kinesiology Questionnaire

Harmony Kinesiology Questionnaire 1^stSession Date _______________

Please Note: This questionnaire has been designed to provide information to assist us in determining how we can

help you. Please answer all the questions as accurately as possible. All information is confidential. If you need

more space to answer any question, please continue on the back of the page.

Name____________________________________Date of Birth ________E-mail ________________________

(including first name and preferred form of address: Ms/Miss/etc)

Address_____________________________________________________________________________________________________

Post Code ______________________Phone No (Day) ________________________Phone No (Eve) ___________________

Referred by___________________________________ Mobile Phone No______________________________

Health Background:

Present state of health________________________________________________________________________

__________________________________________________________________________________________

Present Doctor __________________________________________________Phone No __________________

Present Treatment (including drugs and supplements)

__________________________________________________________________________________________

Lifestyle

Occupation____________________________________ Family _____________________________________
Do you smoke?____________If so, what and how many?____________________________________________

Do you drink?_____________If so, what and how much?____________________________________________

Do you use recreational drugs?______________If so, what and how much?______________________________
Describe a typical day’s eating and drinking: Breakfast______________________________________________

Lunch_____________________________________________________________________________________

Tea (Dinner)________________________________________________________________________________

What kinds of things do you eat/drink between meals?_______________________________________________

__________________________________________________________________________________________

What exercise do you take?____________________________________________________________________

_______________________________________________How long per week?___________________________

What other relaxation do you have?______________________________________________________________

_______________________________________________How often and how long________________________

What time do you normally go to bed? ______ How many hours do you sleep? ______ Quality of sleep?_______

Height ___________________ Weight _________________ Weight five years a go _____________________

Medical History

Was there anything abnormal about your birth? (i.e. premature, method of delivery,etc.)

___________________________________________________________________________________________

Did you have normal childhood vaccinations?___________List and if possible date any since________________

___________________________________________________________________________________________

What was your health like when you were younger?_________________________________________________

___________________________________________________________________________________________

List surgical operations, serious illnesses/injuries/accidents with approximate dates

___________________________________________________________________________________________

List any medication (drugs) taken over a long period ________________________________________________ ___________________________________________________________________________________________

___________________________________________________________________________________________

List any emotional traumas that your remember with approximate dates _________________________________

__________________________________________________________________________________________

Conditions, complaints, problems: In the following, please cross out those items that do not apply to you. If
they do apply, please indicate the degree of severity, in either or both columns by putting:

‘1’ for Mild ‘2’ for Moderate ‘3’ for Severe

I have had	am having		I have had	am having
		poor sleep			regular colds
		vertigo			respiratory infections
		hearing problems/tinnitus			constipation
		dyslexia			loose bowels
		fainting			high blood pressure
		epilepsy			low blood pressure
		nervous twitching			poor circulation
		headaches			cold hands and feet
		migraines			anaemia
		sight problems			chronic tiredness/lethargy
		anxiety attacks			thrush
		depression			menstrual problems
		physical abuse			prostate gland
		emotional abuse			urinary problems
		sexual abuse			sexual dysfunction
		chest pains			liver/gall bladder problems
		neck/shoulder/arm pain			kidney problems
		low back pain/sciatica			asthma
		osteoporosis			hay fever
		arthritis			skin allergies/rashes
		leg/knee pain			other allergies (specify)
		painful feet			food cravings (specify)
		other pain (specify)

Please list in order of importance the problems that you would most like help with:

__________________________________________________________________________________________

Please read and sign the following:

I understand that kinesiologists do not give medical diagnosis or treatment, but do correct imbalances that

are revealed during a session. I give my consent to have kinesiology balance. I give my consent to be

touched in an appropriate manner for a kinesiology balance.

I further appreciate that it is my responsibility to consult my GP about any pain, problem or disease that I

am aware of, or become alerted to the possibility of, as a result of a balance.

I agree to give at least 24 hours notice of cancellation and if not will pay the full fee.

Signed …………………………………………………………………………… Date …………………………….