Horizon Kinesiology - Client Information Form

The most important thing to remember when filling out this questionnaire is that you cannot, under any circumstances what so ever, fail this in any way. Whatever you choose to write as your response will be the correct answer. So please have fun with the questions and enjoy the process. I recommended taking your time with this process and completing the questions over a few days for the best results. If you have any questions, please do not hesitate to contact me via email or telephone for clarification.

First name

Last name

Phone

Address

How did you hear about Horizon Kinesiology?/Who were you referred by?

What is your main issue, problem or condition that you'd like to resolve through working with Horizon Kinesiology.?

Describe any past treatments/therapies you may have received for the above issue, problem or condition.

If you could change one thing in your life right now, what would it be?

What is the key outcome you would like to achieve from our work?

What specifically do you want to cover in your first session that would be the first step in this direction or to help resolve the main issue?

Anything else? Anything else I need to know? Anything else you want to tell me?

Medication: Are you currently taking any medication or supplements?

Sleep

Poor - Broken or less than 5hrs per night

Average - Broken sleep 6 - 8hrs per night

Good - 8hrs per night relatively unbroken

Excellent - Solid 8hrs (or more) per night

Diet

Poor - Highly processed foods/Fast foods & Soft Drinks

Average - Mix of whole natural foods and processed foods & Drinks

Good -Whole natural foods & drinks

Excellent -Whole natural foods & drinks organic as possible

Fluid Intake Per Day

Poor - Very little water, high consumption of Coffee or Tea/Soft Drinks/Alochol

Average - Min 1lt of water per day, some consumption of Coffee or Tea/Soft Drinks/Alcohol

Good - 1-2lts of water per day, Kombucha/Juices/Herbal Teas - Very little consumption of Coffee/Soft Drinks/Alcohol

Excellent - 2-3lts of water per day, Kombucha, Herbal Teas, Juices

Exercise per week

Poor - None

Average - 1 - 3 days per week

Good - 3 - 5 days per week

Excellent - 5 - 7 days per week

Stress Levels out of 10 (1 being low 10 being high) Please describe

Physical Pain out of 10 (1 being low 10 being high) Please describe

Illnesses – Disorders, Accidents, Hospital, Operations - Please Describe

Mental Health Issues, Learning difficulties, Brain injury - Please Describe

Food Preferences or Cravings, Allergies - Please describe

Acknowledgement and Consent

I acknowledge that the above information, to the best of my knowledge, is correct.

Multi choice

I consent to a Neuro-Training Kinesiology & Resolve Beyond Neurology session with the practitioner.

Multi choice

I understand that Neuro-Training Kinesiology & Resolve Beyond Neurology is a touch therapy.

Multi choice

I understand that my personal information will be kept in a secure place and will not be released.

Thank you for taking the time to fill these questions in thoroughly. I look forward watching you grow and evolve over the coming sessions as you create and step into your true voice and heart’s desire.

Here’s to your unprecedented change and unlimited potential!

CONGRATULATIONS ON STOPPING THE STRUGGLE AND ALLOWING CHANGE TO BE MADE WITH EASE & GRACE

Aaron Farrell (Owner/Principal Practitioner) HORIZON KINESIOLOGY

Cert IV: Solution Orientated Neuro-Training & Kinesiology

Cert 1 & Adv Dip: Resolve Beyond Neurology

Dip: Anatomy & Physiology

Kinesiology Association: AIK

www.horizonkinesiology.com.au

aaron@horizonkinesiology.com.au

Ph. 0406 945 844

HORIZON KINESIOLOGY

UNLEASH YOUR GREATEST POTENTIAL

Horizon Kinesiology - Client Information Form