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.
Todays date
Personal details
Your full name
Date of birth age
Cell phone
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 personal life married/divorced/in a relationship etc
What work do you do?
Health
Are you on medication please name them
What illness/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 you diet what do you eat on a daily basis (tea/coffee/ veg/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
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Work
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finances |
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Relationship stress |
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Family stress (parents, children, spouse, brothers, sisters etc) |
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Social life/friends |
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studies |
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health |
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Emotional circumstances/health |
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Spiritual issues |
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Time |
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Life circumstances |
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Past issues |
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Future circumstances |
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Traumatic experiences ) name them |
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Other please specify |
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Other please specify |
What is the biggest stress right now?
How would you describe yourself?
ASSOCIATION OF SPECIALISED KINESIOLOGISTS SOUTH AFRICA
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
 | Does not diagnose or treat any named disease, |
| Does not have the authority to take me off any prescribed medication |
| May suggest courses of action which, if implemented, I will follow entirely of my own volition and as consequence of my own unforced decision. |
| 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.
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Signature of client or parent/guardian Date