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?

Consentimiento informado:

Entiendo que el kinesiólogo holístico utilizará monitorización muscular y otras técnicas holísticas para evaluar y equilibrar mi energía y bienestar general. Reconozco que el kinesiólogo no es un profesional médico colegiado y que esta sesión no sustituye el consejo ni el tratamiento médico. Acepto informar al kinesiólogo sobre cualquier molestia o inquietud que pueda surgir durante la sesión.

Client Signature:

Date:

Message