Darren Smith Kinesiology in Horsham

Pre visit Form. confidential

Confidential Research Information

NAME :

AGE:

SEX:

Before your session

Please note how you feel now .10 being the worst symptom and 0 is no symtoms ie: pain/stress/feelings of any kind. You will be asked to compare how you feel now as to how you feel after your session 01 2 3 4 5 6 7 8 9 10

How did you find out about Systematic Kinesiology?


What problem caused you to contact ?



How long have you had the condition ?


Have you seen anyone else about this problem or what have you done about getting help ?




Please describe how you feel at the moment ?



Are you in pain or discomfort at the moment ?



How do you feel emotionally ?



AFTER YOUR SESSION: How do you feel now ? Physically / Mentally ?





What is your pain or discomfort Now on a scale of 0 1 2 3 4 5 6 7 8 9 10 ?

PLEASE PRINT AND COMPLETE THIS FORM : BRING IT WITH YOU IF YOU CAN OR YOU CAN FILL ONE OUT WHEN YOU ARE HERE !!

DATE OF SESSION :









click
©2019 Darren Smith is powered by WebHealer
Cookies are set by this site. To decline them or find out more visit our cookie page