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Kinesiology Northants Enquiry Form
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Name:
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E-mail Address:
Telephone Number (optional):
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Details of your enquiry:
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Date of Birth:
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Height and Weight:
Blood Group (if known):
GP Name:
Blood Pressure (if known):
Smoker:
Yes
No
Have you ever been a Smoker:
Yes
No
Surgery Address:
Have you ever come for kinesiology?:
How Long have you had these issues?:
What are you hoping to gain/achieve?:
Have you seen a medical practitioner about this?:
Yes
No
If yes please give details (inc dates, outcome etc:
If No (please explain why):
How healthy do you currently feel?:
1 - ILL
2
3
4
5
6
7
8
9
10 - Great
How are these difficulties disrupting your day?:
1 - Not At All
2
3
4
5
6
7
8
9
10 - Major
Do they affect your: (check all that apply):
Work
Socialising
General Mood Enjoyment
Family Life
Were you generally well as a child?:
Yes
No
Details childhood allergies, illnesses & accidents:
What illnesses was/is your mother prone to?:
What illnesses was/is your father prone to?:
Please give ages and sexes of any siblings (30F)?:
Details of any significant health issues they had::
Please give details of long term health issues:
Any major operations or investigations::
Significant illnesses or accidents:
Significant bereavement/loss & approx. date:
Please not any other medical investigations:
Do you have any children (age and sex):
Please state any health problems they have had::
Please check if you have experienced the following:
Digestive Problems
Diarrahoea (travelling/at home)
Constipation
Apetite Loss
Food Cravings
Weight Gain or Loss
Indigestion
Frequent headaches/migraines
Fatgue
Tiredness
Please click on the Submit button to submit the form details.
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