Functional Kinesiology

Please complete this form before your appointment to help us personalize your session.

Full Name

Date of Birth

Email

Phone Number

Emergency Contact (Name & Number)

What are your main health concerns? (e.g., digestion, energy, weight loss, hormonal balance)

Have you been diagnosed with any medical conditions? (e.g., diabetes, thyroid disorders, autoimmune conditions)

Are you currently taking any medications or supplements? (Please list)

Do you have any known food intolerances, allergies, or sensitivities?

Do you experience any of the following regularly? (Check all that apply)

Bloating

Fatigue

Stress or anxiety

Skin issues (eczema, acne, etc.)

Sleep disturbances

Sugar cravings

Brain fog

Joint pain

Hormonal imbalances

Frequent headaches

How would you describe your digestion?

How often do you exercise?

How would you rate your stress levels?

How would you describe your sleep patterns?

Do you have any past injuries, surgeries, or structural imbalances (e.g., back pain, posture issues)?

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