Intake Form

First name

Last name

Phone

Birthday

Address, City, State, Zip

Emergency Contact Name, Relationship

Emergency Contact Phone Number

Health History: Do you have any existing medical conditions or chronic illnesses? If so, please specify:

Are you currently taking any medications or supplements? Please list them:

Have you had any surgeries or medical procedures in the past? If so, please provide details:

Do you have any known allergies (food, medications, environmental, etc.)? If yes, please list them:

Does your family have any existing medical conditions or chronic illnesses? If so, please specify:

Kinesiology Session Specifics: What specific issues, concerns, goals or outcomes would you like to address and hope to achieve?

Lifestyle and Wellness: Describe your current lifestyle, including your diet, exercise routine, and daily activities:

Are there any specific changes you would like to make in your lifestyle or wellness habits?

How do you typically feel on a scale of 1-10, 10 being optimal health?

Informed Consent:

I understand that the holistic kinesiologist will use muscle monitoring and other holistic techniques to assess and balance my energy and overall well-being. I acknowledge that the practitioner is not a licensed medical professional and that this session is not a substitute for medical advice or treatment. I agree to inform the practitioner of any discomfort or concerns during the session.

Client Signature:

Date:

Message