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New Client registration form

 

Thank you for making an appointment to see me.  In order to save time and to get to know you please fill in the form below to the best of your ability and email it to me before our appointment date.

 

 

 

New Client Registration Form

 

Thank you for making an appointment to see me.  In order to save time and to get to know you please fill in the form below to the best of your ability and email it to me before our appointment date.


 


 

Today’s date :

 

Personal details


 

Full Name :

Date of Birth : Age :

Cellphone :

Landline :

Email Address :

Postal Address :

:

Who referred you :

 


 

Why have you chosen a kinesiology session, what do you hope to achieve?


 


 


 

Tell me a little about your personal life (married, divorced, in a relationship, etc.) :


 

 

What work do you do?


 


 


 

Health


 

Are you on medication (please name them)?


 


 


 

What illnesses or operations have you had in the past?


 


 

 

What supplements do you take?


 


 

 

Name of medical doctor or homeopath?


 


 

What is your level of fitness / exercise?


 


 


 

Describe your diet, what do you eat and drink on a daily basis (tea, coffee, vegetables, fruit, sugar, cigarettes, etc.) :


 


 


 

How many glasses of water / tea / coffee / cool drink do you drink a day?


 


 


 

Stress / Frustrations / Worries


 

Please evaluate the following aspects of your life on a scale of 0 to 10.

0 = No stress, frustration or worries. 

10 = Extreme stress, frustration or worries.


 

Work


 

Finances


 

Relationship Stress


 

Family Stress (parents, children, spouse, brothers, sisters, etc.)


 

Social Life / Friends


 

Studies


 

Health


 

Emotional Circumstances


 

Spiritual Issues


 

Time


 

Life Circumstances


 

Past Issues


 

Future Circumstances


 

Traumatic Experiences

(please specify) :


 


 


 

Other (please specify) :


 


 


 


 


 


 


 

 

 

What is your biggest stress right now?

 


 


 

How would you describe yourself?

 

 ASSOCIATION OF SPECIALISED KINESIOLOGISTS SOUTH AFRICA

DISCLAIMER FORM

I, ......................................................, hereby acknowledge that before consulting with me, Angela Hardy made it clear to me that she works in accordance with the terms and conditions of the Code of Ethics and Code of Conduct of the Association of Specialised Kinesiologists, South Africa (ASKSA), as displayed in the practice rooms.

Furthermore, I acknowledge that she :

bullet

Does not diagnose or treat any named disease.

bullet

Does not have the authority to take me off any prescribed medication.

bullet

May suggest courses of action which, if implemented, I will follow entirely of my own volition and as consequence of my own unforced decision.

bullet

May suggest that a specific type of nutrition or essences may be advantageous for me to take, however, the decision on whether to follow her advise is entirely my own.

I have been advised and accept and agree that neither the Association of Specialised Kinesiologists or its individual members or, Angela Hardy, will be responsible or legally liable for any risk of illness, injury or aggravation of any condition including diagnosed or undiagnosed medical conditions, whatsoever that may arise out of advice given or treatment administered to me, nor arising out of my failure to consult with and obtain approval from a medical doctor prior to commencing treatment with Angela Hardy.  I hereby consent to such treatment and indemnify the Association, its members and Angela Hardy against any and all claims by myself my successors and my assigns in this regard.

 

______________________________ __________

Signature of Client or Parent / Guardian Date