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Name: *

E-Mail Address: *

Date of birth: *

Age:

Address: *

Suburb: *

State: *

Post code: *

Phone number: *

Occupation:

Marital Status:

 

Single
Defacto
Married

Number of children:

How did you hear about Melissa Baker Kinesiology?

 

Passed by clinic
Word of mouth
Flyer
Internet
Referral

Now in a courageous fashion, please outline your goals. These could be about your health, relationships, emotions, mental wellbeing, career, finances. Anything your heart desires!

Goal 1

Goal 2

Goal 3

Goal 4

Goal 5

Goal 6

How do you feel at the moment about your goals? Do you feel stuck in any way?

It is helpful for me to know how you feel in regards to areas of your life. We will use this to explore the areas you would like to gain more pleasure and vitality in.

Please rank the following life areas from 1 (lowest pleasure / vitality) to 10 (highest pleasure / vitality):

Health  

1 2 3 4 5 6 7 8 9 10

Any comments

Family & Friends  

1 2 3 4 5 6 7 8 9 10

Any comments

Romance 

1 2 3 4 5 6 7 8 9 10

Any comments

Personal growth 

1 2 3 4 5 6 7 8 9 10

Any comments

Fun & recreation 

1 2 3 4 5 6 7 8 9 10

Any comment

Physical environment  

1 2 3 4 5 6 7 8 9 10

Any comment

Business & career  

1 2 3 4 5 6 7 8 9 10

Any comment

Finances  

1 2 3 4 5 6 7 8 9 10

Any comment

Health background

Do you have any chronic or acute health conditions?

Do you have any allergy symptoms?

Please list any suspected allergies.

Structural issues (joints, spine, muscles)?

Are you on any medications / supplements?

Please detail any history of family illness

Thank you for taking the time to complete this form. Please indicate that you have taken note of the following policies:

Cancellations: Please notify us of cancellations or appointment changes as soon as you can. Cancellations/rescheduling made within 24 hours of your appointment time will incure a cancellation fee. This fee is equal to the cost of your consultation/treatment.

Late arrivals: Although your practitioner will do their best to ensure a full consultation/treatment, late arrivals may have a shortened treatment due to time restrictions.

 

Yes
No

I consent to treatment by Melissa Baker at Melissa Baker Kinesiology. I have read and understood the policies of the practice. I agree for my information to be held by Melissa in secure online database that will not be shared with any 3rd party. I can withdraw my permission at any time. I agree that I take responsibility for my desired wellness outcomes.

Print name as consent

Date

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