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Client Health Questionnaire
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?
Excellent
Good
Sometimes problematic
Often problematic
How often do you exercise?
Daily
A few times per week
Occasionally
Rarely
How would you rate your stress levels?
Low
Moderate
High
How would you describe your sleep patterns?
Restful, uninterrupted
Occasionally disrupted
Frequently disrupted
Do you have any past injuries, surgeries, or structural imbalances (e.g., back pain, posture issues)?
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