Client Form

First Name

Phone

Last Name

Address

Occupation & how long in this job

Birthday required

Spouse / Partners' name

Children (name, age, gender)

Your place in family

No of siblings

Childhood and other illness (inc date, age)

Past trauma /accident / surgery (inc date, age)

Current medication & supplements

Reasons why you are here

Other forms of therapy have you used, like Acupuncture, Chiropractic, Chinese Dr, Physiotherapy, Massage Therapy, other

Exercise: Daily, Twice or more weekly, Fortnightly, Occasional, Never

Emotional & Physical health information and History Anger, Anxiety, Asthma, Pain, Parenting stress, Depression, Diabetes, Digestive problems, Divorce/ separation stress, Insomnia, Epilepsy, Fear, Greif, Headaches, Hearing impairment, Heart problem, Jaw/ Joint pain, Liver damage, Loneliness, High/low pressure, Regret, Vision impairment, weight issue, Work / study stress

Is there anything you wouldn't find easy to tell me? What do you want to feel by the end of this sesion? What particular things would you like me to deal with first?

I declare that the above information in true and correct and indemnify Soul UP Kinesiology of any liability for any false or misleading statements given. It is understood and accepted that the session provided by Soul UP Kinesiology is of a remedial therapeutic nature and not of a diagnostic/curative approach. It is also understood and accepted that the results of the session are not guaranteed in any way. The information gathered here, as well as all notes and information taken in every session, is kept safe and secure in a locked filing cabinet, it will remain the property of Soul UP Kinesiology as part of client history records. Personal information may be used for notification of any future news or services as deemed appropriate. I further understand that payment is to be made at the time of service and can be made by cash. I hereby give permission for Meko Chan to conduct Kinesiology on me. Please ensure you have read all terms, and understand them fully before signing.

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