Initial Consultation Step 1 of 9 - About You 11% General details & contact informationName First Last Date of birth Age Marital Status (single/married/divorced/devacto) Spouse or Partner name (if applicable) Sibling names and ages (if any) Email Skype Username Phone # Occupation Address Street Address Suburb State Postcode Height Weight Emergency contact name Emergency contact number Have you been given a diagnosis for your condition?* Physical activity and general healthCurrent Activities/SportsDo you smoke? If yes, how much? How old were you when you had your first cigarette? * Do you drink alcohol? If yes, how much? * Do you take recreational drugs? If yes, what do you have & how often? * Are you currently on any prescribed medication/ contraception? If yes, please give details... Do you have a swiss ball/ dura disc/ medicine ball? Do you have any allergies? If yes, please give details... Childhood & family lifePlease write a paragraph explaining the character traits and personality of your father:Please write a paragraph explaining the character and personality traits of your mother:Have you experienced any trauma or abuse in your life? Hospitalisations & HistoryHave you been diagnosed with a mental health issue?* Yes No If yes, are you on a Mental Health Plan?Please include details like When you entered the plan & what, if any, treatment you are currently receiving. We are required to ask your Mental Health Professional permission to treat you, please provide their name, address and contact number.Have you been hospitalised recently or ever had surgery/operations? If yes, please give details...Please state any family medical history e.g. cancer, heart disease etc.Please provide information about the following, including the year/your age at the time of illness/injuryInjuries/ accidents:Illness/ virus/ infection:Bone fractures:Spinal disorders:Heart or circulation disorders:Mental/psychological disorders:Any other medical information:Please write a timeline of your injuries/ illness from present to oldest: BiochemicalHow many hours sleep per night are you getting? What time are you getting to sleep/ waking up? How regular are your bowels? On a daily basis how much water do you drink? Do you eat/drink the following: COFFEE TEA SUGAR SWEETS GUM CHOCOLATE GUM CAKES BISCUTS CHEESE MILK (full/lite/other) BREAD MARGARINE PASTA FRIED FOOD ICECREAM YOGURT TAKEAWAY SOFT DRINK CORDIAL CIGGARETTES Do you take any vitamins/ supplements?Are you having any other kinesiology/ other therapy sessions?What facial and body cleansing/ moisturising products/ deodorant/ toothpaste are you currently using? EMGDo you sleep in the same room as a computer/ other electrical devices? Do you sleep with your mobile near your head? Self stress testHow often do you experience stressful situations? Very Often Often Sometimes Rarely Never How often do you feel tired or fatigued for no apparent reason? Very Often Often Sometimes Rarely Never How often do you get less than 8 hours sleep? Very often Often Sometimes Rarely Never How often do you feel anxious or depressed? Very Often Often Sometimes Rarely Never How often do you feel angry or aggressive? Very Often Often Sometimes Rarely Never How often do you feel self conscious or inadequate? Very often Often Sometimes Rarely Never How often do you feel overwhelmed or confused? Very Often Often Sometimes Rarely Never How often is your sex drive lower than you would like it to be? Very Often Often Sometimes Rarely Never Do you tend to gain weight easily? Yes Neutral No Are you currently dieting? Yes No How often have you tried to control your body weight? Very Often Often Sometimes Never How often do you pay close attention to the foods you eat? Very Often Often Sometimes Never How often do you crave carbohydrates (sweets or breads)? Very Often Often Sometimes Rarely Never How often do you experience difficulty with memory or concentration? Very Often Often Sometimes Rarely Never How often do you experience tension headaches or muscle tightness in the head/jaw/neck or shoulder areas? Very Often Often Sometimes Rarely Never How often do you experience digestive problems such as gas, bloating, ulcers, heartburn, constipation or diarrhea? Very Often Often Sometimes Rarely Never How often do you get sick/ catch a cold/ flu/ sore throat? Very Often Often Sometimes Rarely Never Do you have high cholesterol (greater than 200mg/dl)? Yes No Unsure Do you have high blood sugar (greater than 100mg/dl)? Yes No Unsure Do you have high blood pressure (greater than 140/90 mmHg)? Yes No Unsure Do you suffer from... Allergies Angia Anxiety Apathy Asthma Bad breath Bed wetting Breathing without pause Chest t pains (not heart) Constipation Coughing Cramps Dental problems (decay/erosion) Diarrhea Difficulty in swallowing Digestive problems Disturbed sleep problems Dizziness Dry mouth Eczema or other skin problems Excessive mucus production Excessive yawning or sighing Flashes before the eyes Fluid retention Frequent deep breaths Gastric reflux Hemorrhoids Hay fever or rhinitis Head aches High blood pressure High cholesterol Hoarsness Insomnia Irregular or painful periods Irritability Irritable bowel syndrome Kidney problems Loss of feeling in fingers and toes Loss of libedo Loss of memory Loss of smell Mental fatigue Mouth breathing Muscle pains Night time toilet trips Nose bleeds Numbness around the lips Bone pains Pains around the heart region Palpitations Panic attacks Ringing/buzzing in the ears Shortness of breath Shuddering in sleep Sinusitis Sleep apnea Snoring Sweating Thyroid problems Tightness in chest Trembling or tic Varicose veins Weight gain or loss Please answer the following questionsWhat is your typical breakfast?* What is your typical lunch?* What is your typical dinner?* Rate your energy levels in the morning (high/ medium/ low)* Rate your quality of sleep (high/ medium/ low)* Are you currently on a specific diet?* Your goalsPlease state what you hope to achieve by participating in a sports kinesiology program & reason for current visit?What are your health and fitness goals?How did you find Bend Like Bamboo?Would you like to enjoy monthly emails from us of inspiring blogs and news? 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