Confidential Client Questionnaire

All answers you provide are strictly confidential and will only be seen by Toni Miladinov.

In preparation for your first session please complete the relevant information with as much detail as possible. Take time to do it when you are relaxed, so that you remember and write anything that may be relevant to help you get the most from your session(s). All information and discussions are confidential and non-judgemental so please be honest. Except for your contact details, all sections are optional. Your details are used only for our work together. All paperwork is stored in a locked cabinet – no digital copies are kept. All paperwork is destroyed after the legal required period after your final session. Your contact details are for communication purposes only and will not be used for marketing or be made available to any third party.

Personal details

* First Name

* Last Name

_____________________________

* Email Address

* Phone Number

Date of birth

How did you hear about me?

_____________________________

What areas, problems or goals would you most like help with now?

_____________________________

Medical history Medical history

Do you have a Pace Maker? Do you have a Pace Maker? Yes No

Any past surgeries, serious illnesses/injuries, emotional traumas and relationship problems with approx dates

What do you do for exercise and relaxation?

_____________________________

Medication Medication

Any current, or past, medications & what for?

Have you ever reacted to any medication? If yes, what and how?

Alcohol, recreational drugs, smoking? If yes, what, quantity and how often?

_____________________________

* Please read the following statement: * Please read the following statement: I understand that Kinesiologists do not give medical diagnoses or treatment, and that it is my responsibility to consult my GP about any medical problem that I am aware of or become alerted to in the course of a Natural Bioenergetics session.

* SIGNATURE and DATE

* Required * Required

8 + 1 =

Cancellation Policy

Cancellations made later than 24 hours prior to the appointment will be charged at the full rate. Cancellation notice must be made in writing, either by email or text and confirmed by Toni that it has been received. If an appointment can be rescheduled to another time in the same week the penalty charge is waived. Appointments may be rescheduled with 24 hours prior notice.