Confidential Research Information
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 :