Client Assessment Form Name * First Name Last Name Address * Age * Email * Phone (###) ### #### Main health concern/reason for attending * Past medical history * Medications/Supplements * Please give a brief description of your meals * Breakfast Give a brief description * Lunch Give a brief description * Dinner Tea/Coffee * How many cups daily? How much water do you drink daily? * Do you drink alcohol? * If so how much and often? Do you drink juice or fizzy drinks? * Do you smoke or vape? * Please give details if yes How are your stress levels? * How is your sleep? How many hours do you sleep? * Do you suffer from anxiety, depression or low mood? * If so please give details Do you suffer from any skin issues? * Do you have breathing issues? * How is your digestion? * Do you experience any of the following symptoms? Bloating Diarrhea Constipation Acid Reflux Pains or cramps IBS Chrons Colitis When are your symptoms worse? * Morning, evening, after eating etc Have you taken a Covid or Flu Vaccine recently? * Yes No Have you seen a doctor or consultant for any reason? * What are you hoping to get from your appointment? * Any other relevant information? I accept biokinesiology treatment from Regina Sheehy. * I understand that BioKinesionogy is a complementary therapy to be used in conjunction with, an not as an alternative from medical treatment. Yes No Thank you!
