Thank you for booking in to see me. I look forward to helping you with your health.
Please complete the following questions with as much detail as possible.
Your name:
Contact number:
Your email address:
Your address:
Please follow the link and read my Privacy information - and then tick the box to accept the way I work. (In particular, please note that I use your email address to send you my advice, order supplements and keep in touch following appointments.)
Is it ok for me to add you to my email mailing list so I can keep you in touch with my news and offers? (max. 1 email per month!)
Why did you decide to come and see me? What health concerns do you have?
Are you currently receiving any treatment from another practitioner? If so, please give details.
Please list any medication, remedies or supplements you are currently taking or often take:
Please give details of any surgery, hospitalisation, major illness or trauma (accidents):
Please give details of any pain you regularly experience:
How often do you have a bowel movement?
Do you have any digestion issues?
Are there any foods you DON'T eat - and if so, why?
What do you usually have for breakfast?
What do you usually have for lunch?
What do you usually have for your evening meal?
What do you usually drink each day - and how much of each?
If you drink tea/coffee, how do you take it? (milk? sugar? sweeteners?)
Do you usually eat anything outside of the usual three meals a day? If so, what and when?
How would you describe yourself emotionally?
What work do you do?
What hobbies or physical activities do you enjoy?
Who else lives in your house?
Do you have any known allergies?
What time do you usually go to bed and get up?
Is there anything else which you think may be relevant?
How did you hear about me?
I confirm that the information I have given in this form is complete and accurate and I hereby consent to taking part in a Systematic Kinesiology session with Jane Collison.
Thank you for completing this questionnaire.
On the day of your appointment, please:
- Do not take any of your usual supplements (do take prescribed medication as usual)
- Bring with you anything you take regularly - supplements, remedies, medication.
- Wear warm, loose comfortable clothing such as you would wear to a gentle exercise class - shorts, skirts and dresses are not usually practical.
- Bring with you any food or drink items you would like tested for suitability.
I look forward to meeting you and helping you with your health!
Best wishes
Jane
Privacy & Confidentiality: the information in this form is collected by me so that I can provide individual, safe and effective care to you. I keep paper client records for a statutory 7 years. They include a print out of this form (which is not saved on a computer). If you would like to see your records at any time, please ask. If you change your mind about receiving emails from me - please let me know at any time in the future. I will never, ever share your details or any personal information about you with anyone else (unless you have given me permission to speak to another therapist to whom I refer you). I am a Professional member of the Kinesiology Association and bound by their code of ethics. I am professional insured by Balens.
